- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.09 / $179.40 / $420.01
| Professional | | $80.09 | $179.40 | $420.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.10 / $357.29 / $357.29
| Professional | | $303.10 | $357.29 | $357.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.00 / $243.00 / $824.63
| Professional | | $112.00 | $243.00 | $824.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.96 / $265.39 / $824.63
| Professional | | $128.96 | $265.39 | $824.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.61 / $289.76 / $1,012.14
| Professional | | $210.61 | $289.76 | $1,012.14 |