- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.98 / $228.07 / $458.15
| Professional | | $74.98 | $228.07 | $458.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.77 / $295.77 / $1,039.58
| Professional | | $295.77 | $295.77 | $1,039.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.10 / $300.92 / $1,039.58
| Professional | | $104.10 | $300.92 | $1,039.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.87 / $319.27 / $1,039.58
| Professional | | $108.87 | $319.27 | $1,039.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.37 / $367.72 / $1,275.98
| Professional | | $241.37 | $367.72 | $1,275.98 |