- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.36 / $114.78 / $114.78
| Professional | | $74.36 | $114.78 | $114.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $450.00 / $450.00
| Professional | | $450.00 | $450.00 | $450.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.70 / $76.70 / $76.70
| Professional | | $76.70 | $76.70 | $76.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.57 / $107.57 / $107.57
| Professional | | $107.57 | $107.57 | $107.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.30 / $98.35 / $284.95
| Professional | | $75.30 | $98.35 | $284.95 |