- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.29 / $635.29 / $886.72
| Professional | | $324.29 | $635.29 | $886.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.22 / $1,264.18 / $4,457.01
| Professional | | $1,041.22 | $1,264.18 | $4,457.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.29 / $695.73 / $1,847.84
| Professional | | $340.29 | $695.73 | $1,847.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.24 / $847.48 / $1,847.84
| Professional | | $456.24 | $847.48 | $1,847.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.48 / $885.98 / $2,575.60
| Professional | | $664.48 | $885.98 | $2,575.60 |