- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.01 / $498.36 / $704.60
| Professional | | $350.01 | $498.36 | $704.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.07 / $669.64 / $1,057.48
| Professional | | $568.07 | $669.64 | $1,057.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.46 / $600.29 / $1,057.48
| Professional | | $253.46 | $600.29 | $1,057.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.21 / $733.83 / $1,057.48
| Professional | | $375.21 | $733.83 | $1,057.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.91 / $755.86 / $1,297.94
| Professional | | $552.91 | $755.86 | $1,297.94 |