- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $208.93 / $316.23
| Professional | | $109.65 | $208.93 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $218.78 / $302.00
| Professional | | $114.82 | $218.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $218.78 / $398.11
| Professional | | $109.65 | $218.78 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,584.89 / $1,584.89
| Professional | | $1,479.11 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $213.80 / $389.05
| Professional | | $109.65 | $213.80 | $389.05 |