- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.65 / $223.69 / $291.45
| Professional | | $200.65 | $223.69 | $291.45 |
- Facility/Professional
- Professional
- Modifier
- 54
- Low / Median / High Price
- $157.63 / $168.80 / $218.60
| Professional | 54 | $157.63 | $168.80 | $218.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Facility | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.00 / $432.00 / $654.00
| Professional | | $407.00 | $432.00 | $654.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.43 / $420.39 / $638.07
| Professional | | $275.43 | $420.39 | $638.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.74 / $436.03 / $685.10
| Professional | | $306.74 | $436.03 | $685.10 |