- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.27 / $400.25 / $400.25
| Professional | | $374.27 | $400.25 | $400.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $499.16 / $588.40 / $1,553.22
| Professional | | $499.16 | $588.40 | $1,553.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.80 / $572.89 / $1,553.22
| Professional | | $516.80 | $572.89 | $1,553.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.80 / $572.89 / $1,553.22
| Professional | | $516.80 | $572.89 | $1,553.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.81 / $617.09 / $1,652.22
| Professional | | $398.81 | $617.09 | $1,652.22 |