- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.97 / $477.95 / $670.71
| Professional | | $135.97 | $477.95 | $670.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.24 / $620.24 / $1,656.59
| Professional | | $620.24 | $620.24 | $1,656.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.17 / $449.30 / $1,656.59
| Professional | | $182.17 | $449.30 | $1,656.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.05 / $626.39 / $1,656.59
| Professional | | $186.05 | $626.39 | $1,656.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.25 / $602.91 / $2,033.28
| Professional | | $495.25 | $602.91 | $2,033.28 |