- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $112.20 / $125.89
| Professional | | $72.44 | $112.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $204.17
| Professional | | $144.54 | $144.54 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $72.44 / $125.89
| Professional | | $67.61 | $72.44 | $125.89 |