- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.08 / $356.51 / $550.64
| Professional | | $255.08 | $356.51 | $550.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.47 / $721.96 / $1,669.35
| Professional | | $612.47 | $721.96 | $1,669.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.06 / $595.37 / $1,065.86
| Professional | | $391.06 | $595.37 | $1,065.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.09 / $633.47 / $1,065.86
| Professional | | $403.09 | $633.47 | $1,065.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.60 / $669.47 / $1,946.19
| Professional | | $502.60 | $669.47 | $1,946.19 |