- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.35 / $323.86 / $416.36
| Professional | | $200.35 | $323.86 | $416.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.54 / $349.92 / $878.54
| Professional | | $103.54 | $349.92 | $878.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.39 / $396.97 / $809.09
| Professional | | $228.39 | $396.97 | $809.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.45 / $513.45 / $513.45
| Professional | | $513.45 | $513.45 | $513.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.39 / $430.27 / $983.74
| Professional | | $324.39 | $430.27 | $983.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,904.00 / $3,990.72 / $3,990.72
| Professional | | $3,904.00 | $3,990.72 | $3,990.72 |