- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $575.44 / $691.83
| Professional | | $426.58 | $575.44 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $912.01
| Professional | | $295.12 | $295.12 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $870.96 / $1,023.29
| Professional | | $851.14 | $870.96 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $707.95 / $707.95
| Professional | | $489.78 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $426.58
| Professional | | $295.12 | $295.12 | $426.58 |