- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.41 / $567.01 / $567.01
| Professional | | $498.41 | $567.01 | $567.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.65 / $705.65 / $705.65
| Professional | | $705.65 | $705.65 | $705.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.33 / $728.98 / $1,076.88
| Professional | | $467.33 | $728.98 | $1,076.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.51 / $687.69 / $1,076.88
| Professional | | $497.51 | $687.69 | $1,076.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $582.46 / $676.37 / $1,830.83
| Professional | | $582.46 | $676.37 | $1,830.83 |