- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.17 / $214.65 / $618.17
| Professional | | $102.17 | $214.65 | $618.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $634.28
| Professional | | $302.00 | $302.00 | $634.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.92 / $224.43 / $377.83
| Professional | | $127.92 | $224.43 | $377.83 |
- 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
- $177.31 / $265.38 / $508.89
| Professional | | $177.31 | $265.38 | $508.89 |