- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $213.80 / $363.08
| Professional | | $131.83 | $213.80 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $177.83 / $281.84
| Professional | | $100.00 | $177.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $251.19 / $416.87
| Professional | | $147.91 | $251.19 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $218.78 / $380.19
| Professional | | $134.90 | $218.78 | $380.19 |