- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.21 / $295.45 / $460.78
| Professional | | $222.21 | $295.45 | $460.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.20 / $354.16 / $1,055.57
| Professional | | $295.20 | $354.16 | $1,055.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.80 / $361.75 / $1,235.53
| Professional | | $249.80 | $361.75 | $1,235.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.81 / $333.97 / $1,055.57
| Professional | | $252.81 | $333.97 | $1,055.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.28 / $337.99 / $982.56
| Professional | | $217.28 | $337.99 | $982.56 |