- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.79 / $107.47 / $507.56
| Professional | | $89.79 | $107.47 | $507.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.26 / $487.26 / $487.26
| Professional | | $487.26 | $487.26 | $487.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.48 / $548.40 / $1,424.88
| Professional | | $117.48 | $548.40 | $1,424.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.48 / $548.40 / $1,424.88
| Professional | | $117.48 | $548.40 | $1,424.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.41 / $574.79 / $1,748.88
| Professional | | $544.41 | $574.79 | $1,748.88 |