- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.04 / $313.13 / $619.72
| Professional | | $228.04 | $313.13 | $619.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.79 / $403.79 / $1,376.89
| Professional | | $403.79 | $403.79 | $1,376.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.52 / $527.32 / $1,376.89
| Professional | | $306.52 | $527.32 | $1,376.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.19 / $469.88 / $1,376.89
| Professional | | $311.19 | $469.88 | $1,376.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.35 / $535.35 / $1,556.29
| Professional | | $354.35 | $535.35 | $1,556.29 |