- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $275.42 / $489.78
| Professional | | $158.49 | $275.42 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $1,148.15
| Professional | | $346.74 | $346.74 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $371.54 / $1,148.15
| Professional | | $194.98 | $371.54 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $407.38 / $758.58
| Professional | | $316.23 | $407.38 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $309.03 / $691.83
| Professional | | $181.97 | $309.03 | $691.83 |