- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.28 / $108.28 / $346.61
| Professional | | $108.28 | $108.28 | $346.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.49 / $936.49 / $936.49
| Professional | | $936.49 | $936.49 | $936.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.85 / $377.89 / $936.49
| Professional | | $118.85 | $377.89 | $936.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.85 / $377.89 / $936.49
| Professional | | $118.85 | $377.89 | $936.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.19 / $410.91 / $1,149.44
| Professional | | $389.19 | $410.91 | $1,149.44 |