- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.44 / $414.44 / $1,264.44
| Professional | | $414.44 | $414.44 | $1,264.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.93 / $418.66 / $418.66
| Professional | | $384.93 | $418.66 | $418.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.58 / $561.01 / $744.46
| Professional | | $446.58 | $561.01 | $744.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.81 / $526.52 / $807.70
| Professional | | $408.81 | $526.52 | $807.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.44 / $414.44 / $1,454.10
| Professional | | $414.44 | $414.44 | $1,454.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.32 / $521.71 / $708.09
| Professional | | $354.32 | $521.71 | $708.09 |