- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.68 / $195.17 / $517.33
| Professional | | $103.68 | $195.17 | $517.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.00 / $304.00 / $1,676.54
| Professional | | $304.00 | $304.00 | $1,676.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.59 / $193.69 / $273.94
| Professional | | $114.59 | $193.69 | $273.94 |
- 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
- $111.35 / $152.91 / $304.61
| Professional | | $111.35 | $152.91 | $304.61 |