- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.89 / $136.30 / $351.91
| Professional | | $97.89 | $136.30 | $351.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.00 / $257.00 / $257.00
| Professional | | $257.00 | $257.00 | $257.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.29 / $180.38 / $261.62
| Professional | | $109.29 | $180.38 | $261.62 |
- 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
- $120.25 / $156.19 / $281.73
| Professional | | $120.25 | $156.19 | $281.73 |