- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.34 / $126.73 / $182.98
| Professional | | $110.34 | $126.73 | $182.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Professional | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.59 / $138.56 / $181.07
| Professional | | $106.59 | $138.56 | $181.07 |
- 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
- $94.04 / $120.13 / $161.87
| Professional | | $94.04 | $120.13 | $161.87 |