- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.83 / $227.27 / $252.11
| Professional | | $101.83 | $227.27 | $252.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $123.00 / $123.00
| Professional | | $123.00 | $123.00 | $123.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.44 / $108.94 / $215.46
| Professional | | $60.44 | $108.94 | $215.46 |
- 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
- $47.16 / $121.04 / $231.30
| Professional | | $47.16 | $121.04 | $231.30 |