- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.49 / $250.79 / $623.20
| Professional | | $112.49 | $250.79 | $623.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.86 / $246.31 / $500.86
| Professional | | $118.86 | $246.31 | $500.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.33 / $493.41 / $687.50
| Professional | | $262.33 | $493.41 | $687.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.83 / $583.05 / $1,966.88
| Professional | | $324.83 | $583.05 | $1,966.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.00 / $403.38 / $687.50
| Professional | | $264.00 | $403.38 | $687.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $168.40 / $737.80
| Professional | | $5.00 | $168.40 | $737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.55 / $548.69 / $647.79
| Professional | | $329.55 | $548.69 | $647.79 |