- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.31 / $120.31 / $228.65
| Professional | | $75.31 | $120.31 | $228.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.00 / $222.00 / $222.00
| Professional | | $222.00 | $222.00 | $222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.10 / $150.00 / $237.74
| Professional | | $103.10 | $150.00 | $237.74 |
- 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
- $106.45 / $134.82 / $263.68
| Professional | | $106.45 | $134.82 | $263.68 |