- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.97 / $269.80 / $852.93
| Professional | | $158.97 | $269.80 | $852.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $1,158.63
| Professional | | $346.11 | $346.11 | $1,158.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.05 / $363.92 / $1,158.63
| Professional | | $220.05 | $363.92 | $1,158.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.15 / $376.15 / $1,158.63
| Professional | | $222.15 | $376.15 | $1,158.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.08 / $416.50 / $1,422.09
| Professional | | $309.08 | $416.50 | $1,422.09 |