- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.25 / $236.39 / $430.60
| Professional | | $128.25 | $236.39 | $430.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.00 / $292.00 / $292.00
| Professional | | $292.00 | $292.00 | $292.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.35 / $174.66 / $370.44
| Professional | | $93.35 | $174.66 | $370.44 |
- 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
- $198.93 / $261.08 / $387.18
| Professional | | $198.93 | $261.08 | $387.18 |