- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $268.55 / $1,115.27
| Professional | | $100.00 | $268.55 | $1,115.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.07 / $335.07 / $394.98
| Professional | | $335.07 | $335.07 | $394.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.06 / $274.62 / $886.81
| Professional | | $222.06 | $274.62 | $886.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.06 / $250.65 / $886.81
| Professional | | $222.06 | $250.65 | $886.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.37 / $329.06 / $1,088.46
| Professional | | $270.37 | $329.06 | $1,088.46 |