- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.25 / $399.05 / $2,148.67
| Professional | | $326.25 | $399.05 | $2,148.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.93 / $505.93 / $1,470.78
| Professional | | $505.93 | $505.93 | $1,470.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.16 / $687.81 / $1,470.78
| Professional | | $351.16 | $687.81 | $1,470.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.15 / $670.14 / $1,470.78
| Professional | | $428.15 | $670.14 | $1,470.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.60 / $577.72 / $1,805.22
| Professional | | $460.60 | $577.72 | $1,805.22 |