- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $208.93 / $331.13
| Professional | | $109.65 | $208.93 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $331.13
| Professional | | $169.82 | $169.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $234.42 / $398.11
| Professional | | $125.89 | $234.42 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $302.00 / $1,479.11
| Professional | | $234.42 | $302.00 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $234.42 / $338.84
| Professional | | $123.03 | $234.42 | $338.84 |