- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.31 / $291.13 / $632.46
| Professional | | $133.31 | $291.13 | $632.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.63 / $449.63 / $1,100.92
| Professional | | $449.63 | $449.63 | $1,100.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.07 / $300.92 / $1,100.92
| Professional | | $176.07 | $300.92 | $1,100.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.42 / $447.96 / $1,100.92
| Professional | | $190.42 | $447.96 | $1,100.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.77 / $414.93 / $1,351.26
| Professional | | $389.77 | $414.93 | $1,351.26 |