- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.37 / $319.24 / $540.95
| Professional | | $203.37 | $319.24 | $540.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.01 / $480.80 / $1,395.76
| Professional | | $396.01 | $480.80 | $1,395.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.19 / $457.19 / $1,225.36
| Professional | | $284.19 | $457.19 | $1,225.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.52 / $499.26 / $1,225.36
| Professional | | $288.52 | $499.26 | $1,225.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.72 / $421.24 / $1,413.68
| Professional | | $364.72 | $421.24 | $1,413.68 |