- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.52 / $146.83 / $234.90
| Professional | | $114.52 | $146.83 | $234.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.00 / $167.00 / $167.00
| Professional | | $167.00 | $167.00 | $167.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.35 / $163.76 / $236.86
| Professional | | $109.35 | $163.76 | $236.86 |
- 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
- $105.67 / $145.34 / $211.62
| Professional | | $105.67 | $145.34 | $211.62 |