- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.29 / $947.65 / $947.65
| Professional | | $821.29 | $947.65 | $947.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.82 / $1,010.82 / $1,152.33
| Professional | | $1,010.82 | $1,010.82 | $1,152.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $669.67 / $669.67 / $669.67
| Professional | | $669.67 | $669.67 | $669.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.53 / $1,453.06 / $1,895.30
| Professional | | $1,263.53 | $1,453.06 | $1,895.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $568.59 / $1,137.18
| Professional | | $530.67 | $568.59 | $1,137.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.77 / $631.77 / $631.77
| Professional | | $631.77 | $631.77 | $631.77 |