- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.62 / $249.37 / $791.19
| Professional | | $155.62 | $249.37 | $791.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.56 / $394.37 / $1,141.77
| Professional | | $334.56 | $394.37 | $1,141.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.67 / $376.04 / $1,141.77
| Professional | | $236.67 | $376.04 | $1,141.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.16 / $387.99 / $1,141.77
| Professional | | $249.16 | $387.99 | $1,141.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.39 / $418.38 / $1,401.39
| Professional | | $303.39 | $418.38 | $1,401.39 |