- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $478.63 / $724.44
| Professional | | $371.54 | $478.63 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $870.96 / $1,479.11
| Professional | | $575.44 | $870.96 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $1,905.46
| Professional | | $758.58 | $1,288.25 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,071.52 / $1,737.80
| Professional | | $724.44 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $1,047.13 / $2,691.53
| Professional | | $549.54 | $1,047.13 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $870.96 / $1,698.24
| Professional | | $467.74 | $870.96 | $1,698.24 |