- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.80 / $575.72 / $575.72
| Professional | | $410.80 | $575.72 | $575.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.61 / $651.05 / $940.42
| Professional | | $543.61 | $651.05 | $940.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.40 / $694.60 / $1,089.45
| Professional | | $562.40 | $694.60 | $1,089.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.60 / $700.11 / $1,074.01
| Professional | | $543.60 | $700.11 | $1,074.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.80 / $575.72 / $575.72
| Professional | | $410.80 | $575.72 | $575.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.42 / $785.54 / $996.17
| Professional | | $573.42 | $785.54 | $996.17 |