- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $630.96 / $954.99
| Professional | | $512.86 | $630.96 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $794.33 / $1,258.93
| Professional | | $512.86 | $794.33 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $2,137.96
| Professional | | $575.44 | $1,023.29 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $912.01 / $1,380.38
| Professional | | $562.34 | $912.01 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,000.00 / $1,862.09
| Professional | | $630.96 | $1,000.00 | $1,862.09 |