- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.50 / $457.08 / $815.84
| Professional | | $282.50 | $457.08 | $815.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $540.83 / $540.83 / $1,741.98
| Professional | | $540.83 | $540.83 | $1,741.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.57 / $638.53 / $1,741.98
| Professional | | $366.57 | $638.53 | $1,741.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.50 / $640.95 / $1,741.98
| Professional | | $420.50 | $640.95 | $1,741.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.40 / $674.94 / $2,138.09
| Professional | | $493.40 | $674.94 | $2,138.09 |