- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.04 / $323.04 / $323.04
| Professional | | $323.04 | $323.04 | $323.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.54 / $807.54 / $807.54
| Professional | | $807.54 | $807.54 | $807.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.74 / $389.22 / $807.54
| Professional | | $352.74 | $389.22 | $807.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.74 / $389.22 / $807.54
| Professional | | $352.74 | $389.22 | $807.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.11 / $323.19 / $991.17
| Professional | | $306.11 | $323.19 | $991.17 |