- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.16 / $219.16 / $1,037.53
| Professional | | $219.16 | $219.16 | $1,037.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.54 / $238.54 / $238.54
| Professional | | $238.54 | $238.54 | $238.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.65 / $326.49 / $678.60
| Professional | | $161.65 | $326.49 | $678.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.08 / $327.31 / $678.60
| Professional | | $273.08 | $327.31 | $678.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.83 / $279.89 / $832.91
| Professional | | $264.83 | $279.89 | $832.91 |