- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.14 / $368.53 / $1,313.92
| Professional | | $268.14 | $368.53 | $1,313.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.93 / $420.93 / $1,350.97
| Professional | | $420.93 | $420.93 | $1,350.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.58 / $481.42 / $1,350.97
| Professional | | $281.58 | $481.42 | $1,350.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.50 / $507.85 / $1,350.97
| Professional | | $337.50 | $507.85 | $1,350.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.52 / $507.91 / $1,658.16
| Professional | | $391.52 | $507.91 | $1,658.16 |