- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.68 / $513.57 / $914.83
| Professional | | $340.68 | $513.57 | $914.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $646.11 / $784.47 / $2,403.92
| Professional | | $646.11 | $784.47 | $2,403.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.94 / $724.98 / $1,774.44
| Professional | | $480.94 | $724.98 | $1,774.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.04 / $764.10 / $1,774.44
| Professional | | $481.04 | $764.10 | $1,774.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.62 / $716.70 / $2,083.50
| Professional | | $521.62 | $716.70 | $2,083.50 |