- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.69 / $425.92 / $639.51
| Professional | | $304.69 | $425.92 | $639.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.09 / $725.17 / $1,078.82
| Professional | | $673.09 | $725.17 | $1,078.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.77 / $550.42 / $1,078.82
| Professional | | $259.77 | $550.42 | $1,078.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $377.95 / $747.93 / $1,078.82
| Professional | | $377.95 | $747.93 | $1,078.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.91 / $774.09 / $1,324.13
| Professional | | $640.91 | $774.09 | $1,324.13 |