- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.32 / $332.79 / $416.04
| Professional | | $219.32 | $332.79 | $416.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.45 / $416.45 / $1,127.60
| Professional | | $416.45 | $416.45 | $1,127.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.42 / $428.74 / $1,127.60
| Professional | | $286.42 | $428.74 | $1,127.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.42 / $428.74 / $1,127.60
| Professional | | $286.42 | $428.74 | $1,127.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.95 / $440.73 / $1,384.02
| Professional | | $381.95 | $440.73 | $1,384.02 |