- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.52 / $555.29 / $595.26
| Professional | | $410.52 | $555.29 | $595.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,660.11 / $1,660.11 / $1,660.11
| Professional | | $1,660.11 | $1,660.11 | $1,660.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.15 / $800.94 / $1,046.18
| Professional | | $522.15 | $800.94 | $1,046.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.26 / $703.42 / $1,046.18
| Professional | | $487.26 | $703.42 | $1,046.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $634.19 / $657.09 / $1,910.21
| Professional | | $634.19 | $657.09 | $1,910.21 |