- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.13 / $274.98 / $1,194.65
| Professional | | $188.13 | $274.98 | $1,194.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.44 / $834.64 / $834.64
| Professional | | $401.44 | $834.64 | $834.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.06 / $281.70 / $834.64
| Professional | | $174.06 | $281.70 | $834.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.87 / $360.69 / $834.64
| Professional | | $229.87 | $360.69 | $834.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.08 / $318.95 / $1,024.43
| Professional | | $302.08 | $318.95 | $1,024.43 |