- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.97 / $538.97 / $538.97
| Professional | | $538.97 | $538.97 | $538.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.73 / $516.73 / $1,335.75
| Professional | | $516.73 | $516.73 | $1,335.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.05 / $641.48 / $1,335.75
| Professional | | $605.05 | $641.48 | $1,335.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $605.05 / $641.48 / $1,335.75
| Professional | | $605.05 | $641.48 | $1,335.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.97 / $582.29 / $1,639.49
| Professional | | $536.97 | $582.29 | $1,639.49 |