- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.49 / $132.30 / $197.22
| Professional | | $97.49 | $132.30 | $197.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.00 / $187.00 / $187.00
| Professional | | $187.00 | $187.00 | $187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.20 / $172.46 / $201.90
| Professional | | $108.20 | $172.46 | $201.90 |
- 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
- $93.39 / $120.50 / $267.75
| Professional | | $93.39 | $120.50 | $267.75 |