- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.25 / $196.57 / $359.97
| Professional | | $180.25 | $196.57 | $359.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.80 / $1,105.80 / $1,105.80
| Professional | | $1,105.80 | $1,105.80 | $1,105.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.48 / $329.62 / $657.97
| Professional | | $207.48 | $329.62 | $657.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.59 / $335.29 / $657.97
| Professional | | $208.59 | $335.29 | $657.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.75 / $413.27 / $696.84
| Professional | | $279.75 | $413.27 | $696.84 |