- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.54 / $108.50 / $166.12
| Professional | | $91.54 | $108.50 | $166.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.47 / $159.47 / $159.47
| Professional | | $159.47 | $159.47 | $159.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.27 / $181.32 / $469.44
| Professional | | $119.27 | $181.32 | $469.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.27 / $181.32 / $469.44
| Professional | | $119.27 | $181.32 | $469.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.28 / $189.32 / $576.17
| Professional | | $176.28 | $189.32 | $576.17 |