- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.04 / $276.00 / $725.94
| Professional | | $139.04 | $276.00 | $725.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.83 / $609.45 / $993.61
| Professional | | $586.83 | $609.45 | $993.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.50 / $286.83 / $467.42
| Professional | | $190.50 | $286.83 | $467.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.75 / $286.83 / $467.42
| Professional | | $183.75 | $286.83 | $467.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.68 / $384.58 / $1,118.00
| Professional | | $317.68 | $384.58 | $1,118.00 |