- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.65 / $375.93 / $539.36
| Professional | | $359.65 | $375.93 | $539.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.85 / $695.31 / $1,634.85
| Professional | | $589.85 | $695.31 | $1,634.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.45 / $595.32 / $1,036.85
| Professional | | $404.45 | $595.32 | $1,036.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.06 / $628.52 / $1,036.85
| Professional | | $420.06 | $628.52 | $1,036.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $497.36 / $651.24 / $1,893.20
| Professional | | $497.36 | $651.24 | $1,893.20 |