- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.16 / $623.30 / $628.45
| Professional | | $519.16 | $623.30 | $628.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,897.54 / $1,897.54 / $1,897.54
| Professional | | $1,897.54 | $1,897.54 | $1,897.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.42 / $789.31 / $1,180.56
| Professional | | $541.42 | $789.31 | $1,180.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.98 / $738.74 / $1,180.56
| Professional | | $547.98 | $738.74 | $1,180.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.28 / $741.50 / $2,155.58
| Professional | | $516.28 | $741.50 | $2,155.58 |