- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $425.00 / $522.50
| Professional | | $370.50 | $425.00 | $522.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.28 / $568.50 / $1,497.59
| Professional | | $482.28 | $568.50 | $1,497.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.17 / $546.49 / $1,497.59
| Professional | | $512.17 | $546.49 | $1,497.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.17 / $546.22 / $1,497.59
| Professional | | $512.17 | $546.22 | $1,497.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.46 / $817.90 / $1,482.45
| Professional | | $394.46 | $817.90 | $1,482.45 |