- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.63 / $192.51 / $423.90
| Professional | | $112.63 | $192.51 | $423.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Professional | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.50 / $209.82 / $448.28
| Professional | | $117.50 | $209.82 | $448.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.85 / $260.33 / $503.20
| Professional | | $199.85 | $260.33 | $503.20 |