- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.44 / $420.74 / $1,522.73
| Professional | | $307.44 | $420.74 | $1,522.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.46 / $494.46 / $494.46
| Professional | | $494.46 | $494.46 | $494.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.93 / $568.79 / $1,553.86
| Professional | | $319.93 | $568.79 | $1,553.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.11 / $575.19 / $1,553.86
| Professional | | $394.11 | $575.19 | $1,553.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $452.14 / $591.79 / $1,907.19
| Professional | | $452.14 | $591.79 | $1,907.19 |