- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.00 / $20.00 / $128.86
| Professional | | $20.00 | $20.00 | $128.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.32 / $261.32 / $261.32
| Professional | | $261.32 | $261.32 | $261.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.20 / $291.33 / $291.33
| Professional | | $262.20 | $291.33 | $291.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $20.00 / $21.40 / $141.75
| Facility | | $20.00 | $21.40 | $141.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.33 / $291.33 / $291.33
| Professional | | $291.33 | $291.33 | $291.33 |