- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $603.90 / $718.38 / $718.38
| Professional | | $603.90 | $718.38 | $718.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.46 / $1,221.75 / $2,170.54
| Professional | | $1,036.46 | $1,221.75 | $2,170.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.50 / $1,030.40 / $1,344.53
| Professional | | $658.50 | $1,030.40 | $1,344.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $658.50 / $889.49 / $1,344.53
| Professional | | $658.50 | $889.49 | $1,344.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.10 / $830.73 / $2,454.96
| Professional | | $740.10 | $830.73 | $2,454.96 |