- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.00 / $783.60 / $848.25
| Professional | | $585.00 | $783.60 | $848.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,352.79 / $2,352.79 / $2,352.79
| Professional | | $2,352.79 | $2,352.79 | $2,352.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.39 / $1,126.55 / $1,474.57
| Professional | | $738.39 | $1,126.55 | $1,474.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.84 / $1,009.57 / $1,474.57
| Professional | | $686.84 | $1,009.57 | $1,474.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.45 / $926.16 / $2,692.40
| Professional | | $909.45 | $926.16 | $2,692.40 |