- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.54 / $430.60 / $1,495.89
| Professional | | $234.54 | $430.60 | $1,495.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.41 / $621.41 / $1,447.43
| Professional | | $621.41 | $621.41 | $1,447.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.40 / $594.65 / $1,447.43
| Professional | | $385.40 | $594.65 | $1,447.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.25 / $628.44 / $1,447.43
| Professional | | $476.25 | $628.44 | $1,447.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $515.26 / $597.82 / $1,776.56
| Professional | | $515.26 | $597.82 | $1,776.56 |