- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.85 / $344.85 / $365.38
| Professional | | $344.85 | $344.85 | $365.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.00 / $108.00 / $108.00
| Professional | | $108.00 | $108.00 | $108.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.53 / $105.53 / $105.53
| Facility | | $105.53 | $105.53 | $105.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $109.45 / $136.81
| Professional | | $109.45 | $109.45 | $136.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.07 / $751.07 / $751.07
| Professional | | $751.07 | $751.07 | $751.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.85 / $344.85 / $381.99
| Professional | | $344.85 | $344.85 | $381.99 |