- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.56 / $246.72 / $1,189.00
| Professional | | $155.56 | $246.72 | $1,189.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.84 / $912.84 / $912.84
| Professional | | $912.84 | $912.84 | $912.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.44 / $351.52 / $912.84
| Professional | | $191.44 | $351.52 | $912.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.43 / $376.19 / $912.84
| Professional | | $236.43 | $376.19 | $912.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.56 / $355.12 / $1,120.41
| Professional | | $313.56 | $355.12 | $1,120.41 |