- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.74 / $282.22 / $1,359.44
| Professional | | $120.74 | $282.22 | $1,359.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.94 / $993.94 / $993.94
| Professional | | $993.94 | $993.94 | $993.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.34 / $265.58 / $993.94
| Professional | | $163.34 | $265.58 | $993.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.20 / $345.65 / $993.94
| Professional | | $175.20 | $345.65 | $993.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.02 / $360.35 / $1,219.95
| Professional | | $277.02 | $360.35 | $1,219.95 |