- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.89 / $207.49 / $589.20
| Professional | | $101.89 | $207.49 | $589.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.61 / $312.00 / $312.00
| Professional | | $128.61 | $312.00 | $312.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.38 / $219.95 / $408.29
| Professional | | $123.38 | $219.95 | $408.29 |
- 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
- $188.79 / $254.00 / $545.30
| Professional | | $188.79 | $254.00 | $545.30 |