- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $602.56 / $831.76
| Professional | | $407.38 | $602.56 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $812.83 / $1,202.26
| Professional | | $758.58 | $812.83 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $588.84 / $1,202.26
| Professional | | $436.52 | $588.84 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,202.26
| Professional | | $562.34 | $562.34 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $741.31 / $1,258.93
| Professional | | $323.59 | $741.31 | $1,258.93 |