- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.41 / $263.45 / $1,125.13
| Professional | | $169.41 | $263.45 | $1,125.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.08 / $795.08 / $795.08
| Professional | | $795.08 | $795.08 | $795.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.37 / $231.97 / $795.08
| Professional | | $141.37 | $231.97 | $795.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.88 / $299.45 / $795.08
| Professional | | $184.88 | $299.45 | $795.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.75 / $366.25 / $975.87
| Professional | | $284.75 | $366.25 | $975.87 |