- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.58 / $341.83 / $398.25
| Professional | | $259.58 | $341.83 | $398.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.77 / $703.74 / $954.93
| Professional | | $543.77 | $703.74 | $954.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.40 / $728.57 / $1,022.68
| Professional | | $409.40 | $728.57 | $1,022.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.32 / $725.99 / $2,042.32
| Professional | | $401.32 | $725.99 | $2,042.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.32 / $710.34 / $854.13
| Professional | | $401.32 | $710.34 | $854.13 |