- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.49 / $354.86 / $472.03
| Professional | | $255.49 | $354.86 | $472.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,405.30 / $1,405.30 / $1,405.30
| Professional | | $1,405.30 | $1,405.30 | $1,405.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.27 / $542.09 / $889.29
| Professional | | $354.27 | $542.09 | $889.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.99 / $553.41 / $889.29
| Professional | | $403.99 | $553.41 | $889.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $444.68 / $549.45 / $1,623.73
| Professional | | $444.68 | $549.45 | $1,623.73 |