- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.40 / $393.40 / $1,291.95
| Professional | | $393.40 | $393.40 | $1,291.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.37 / $801.37 / $801.37
| Professional | | $801.37 | $801.37 | $801.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.00 / $604.00 / $604.00
| Professional | | $604.00 | $604.00 | $604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.91 / $1,743.99 / $3,102.30
| Professional | | $1,120.91 | $1,743.99 | $3,102.30 |