- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.41 / $495.80 / $637.37
| Professional | | $355.41 | $495.80 | $637.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.60 / $1,949.60 / $1,949.60
| Professional | | $1,949.60 | $1,949.60 | $1,949.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.96 / $736.43 / $1,196.57
| Professional | | $520.96 | $736.43 | $1,196.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.96 / $720.59 / $1,196.57
| Professional | | $547.96 | $720.59 | $1,196.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.38 / $728.98 / $1,228.58
| Professional | | $667.38 | $728.98 | $1,228.58 |