- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.76 / $113.44 / $210.36
| Professional | | $70.76 | $113.44 | $210.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.00 / $217.00 / $217.00
| Professional | | $217.00 | $217.00 | $217.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.86 / $147.85 / $228.72
| Professional | | $98.86 | $147.85 | $228.72 |
- 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
- $100.24 / $128.35 / $256.72
| Professional | | $100.24 | $128.35 | $256.72 |