- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.90 / $177.73 / $276.77
| Professional | | $78.90 | $177.73 | $276.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.76 / $197.76 / $197.76
| Professional | | $197.76 | $197.76 | $197.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.94 / $114.94 / $223.40
| Professional | | $114.94 | $114.94 | $223.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $319.27 / $558.74
| Professional | | $100.00 | $319.27 | $558.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.87 / $119.47 / $171.39
| Professional | | $99.87 | $119.47 | $171.39 |