- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.47 / $622.47 / $658.45
| Professional | | $622.47 | $622.47 | $658.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.88 / $899.27 / $2,004.89
| Professional | | $762.88 | $899.27 | $2,004.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $609.47 / $891.93 / $1,240.91
| Professional | | $609.47 | $891.93 | $1,240.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.70 / $823.28 / $1,240.91
| Professional | | $573.70 | $823.28 | $1,240.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.70 / $766.70 / $2,265.75
| Professional | | $626.70 | $766.70 | $2,265.75 |