- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.62 / $529.87 / $530.90
| Professional | | $380.62 | $529.87 | $530.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $671.03 / $790.99 / $1,634.37
| Professional | | $671.03 | $790.99 | $1,634.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.70 / $751.34 / $1,001.00
| Professional | | $509.70 | $751.34 | $1,001.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.70 / $661.17 / $1,001.00
| Professional | | $509.70 | $661.17 | $1,001.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.71 / $628.71 / $1,827.71
| Professional | | $540.71 | $628.71 | $1,827.71 |