- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.26 / $536.54 / $686.39
| Professional | | $67.26 | $536.54 | $686.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.66 / $869.66 / $2,209.44
| Professional | | $869.66 | $869.66 | $2,209.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.59 / $321.29 / $2,209.44
| Professional | | $100.59 | $321.29 | $2,209.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.74 / $767.90 / $2,209.44
| Professional | | $113.74 | $767.90 | $2,209.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.98 / $861.62 / $2,711.84
| Professional | | $676.98 | $861.62 | $2,711.84 |