- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $691.83
| Professional | | $660.69 | $660.69 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $660.69 / $1,230.27
| Professional | | $660.69 | $660.69 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,479.11 / $1,698.24
| Professional | | $1,288.25 | $1,479.11 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $173.78 / $218.78
| Professional | | $144.54 | $173.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $933.25 / $1,737.80
| Professional | | $125.89 | $933.25 | $1,737.80 |