- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.78 / $224.78 / $760.13
| Professional | | $224.78 | $224.78 | $760.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.36 / $160.36 / $222.50
| Professional | | $160.36 | $160.36 | $222.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.00 / $342.00 / $342.00
| Professional | | $342.00 | $342.00 | $342.00 |
- 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
- $667.20 / $1,071.14 / $1,843.59
| Professional | | $667.20 | $1,071.14 | $1,843.59 |