- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.94 / $138.35 / $219.40
| Professional | | $46.94 | $138.35 | $219.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.00 / $162.00 / $162.00
| Professional | | $162.00 | $162.00 | $162.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.77 / $135.32 / $212.44
| Professional | | $51.77 | $135.32 | $212.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $83.66
| Professional | | $32.34 | $32.34 | $83.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.17 / $148.08 / $193.15
| Professional | | $112.17 | $148.08 | $193.15 |