- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.50 / $240.84 / $1,114.77
| Professional | | $160.50 | $240.84 | $1,114.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.95 / $258.95 / $305.25
| Professional | | $258.95 | $258.95 | $305.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.16 / $225.69 / $823.64
| Professional | | $145.16 | $225.69 | $823.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.16 / $225.69 / $823.64
| Professional | | $145.16 | $225.69 | $823.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.59 / $298.47 / $1,010.93
| Professional | | $242.59 | $298.47 | $1,010.93 |