- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.27 / $223.62 / $315.83
| Professional | | $115.27 | $223.62 | $315.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.00 / $242.00 / $242.00
| Professional | | $242.00 | $242.00 | $242.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.72 / $210.30 / $264.77
| Professional | | $116.72 | $210.30 | $264.77 |
- 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
- $114.00 / $149.38 / $300.10
| Professional | | $114.00 | $149.38 | $300.10 |