- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.08 / $353.97 / $398.72
| Professional | | $255.08 | $353.97 | $398.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.42 / $475.54 / $1,240.54
| Professional | | $403.42 | $475.54 | $1,240.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.53 / $527.10 / $744.81
| Professional | | $345.53 | $527.10 | $744.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.56 / $491.46 / $744.81
| Professional | | $410.56 | $491.46 | $744.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.10 / $467.81 / $1,359.96
| Professional | | $384.10 | $467.81 | $1,359.96 |