- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.61 / $262.61 / $1,376.18
| Professional | | $262.61 | $262.61 | $1,376.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.50 / $220.11 / $220.11
| Professional | | $202.50 | $220.11 | $220.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.70 / $312.63 / $447.03
| Professional | | $267.70 | $312.63 | $447.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.88 / $316.67 / $485.79
| Professional | | $245.88 | $316.67 | $485.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.61 / $262.61 / $1,431.77
| Professional | | $262.61 | $262.61 | $1,431.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.34 / $289.88 / $408.61
| Professional | | $201.34 | $289.88 | $408.61 |