- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.45 / $73.37 / $350.00
| Professional | | $38.45 | $73.37 | $350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.33 / $252.55 / $479.58
| Professional | | $127.33 | $252.55 | $479.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.12 / $482.80 / $1,025.08
| Professional | | $118.12 | $482.80 | $1,025.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.77 / $393.88 / $668.97
| Professional | | $331.77 | $393.88 | $668.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.26 / $59.40 / $498.07
| Professional | | $37.26 | $59.40 | $498.07 |