- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.09 / $240.55 / $927.00
| Professional | | $150.09 | $240.55 | $927.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.92 / $875.92 / $875.92
| Professional | | $875.92 | $875.92 | $875.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.38 / $300.92 / $875.92
| Professional | | $178.38 | $300.92 | $875.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.54 / $328.55 / $875.92
| Professional | | $232.54 | $328.55 | $875.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.55 / $451.46 / $1,075.09
| Professional | | $294.55 | $451.46 | $1,075.09 |