- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.99 / $574.14 / $803.80
| Professional | | $120.99 | $574.14 | $803.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.07 / $108.04 / $337.60
| Professional | | $93.07 | $108.04 | $337.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.72 / $134.72 / $134.72
| Professional | | $134.72 | $134.72 | $134.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.81 / $502.92 / $1,013.22
| Professional | | $341.81 | $502.92 | $1,013.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $3,000.00 / $4,735.00
| Professional | | $2,500.00 | $3,000.00 | $4,735.00 |