- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.07 / $290.58 / $325.69
| Professional | | $121.07 | $290.58 | $325.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.00 / $301.00 / $301.00
| Professional | | $301.00 | $301.00 | $301.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.45 / $183.19 / $255.05
| Professional | | $122.45 | $183.19 | $255.05 |
- 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
- $122.45 / $168.71 / $338.93
| Professional | | $122.45 | $168.71 | $338.93 |