- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.44 / $734.31 / $734.31
| Professional | | $607.44 | $734.31 | $734.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.57 / $1,035.65 / $2,060.88
| Professional | | $878.57 | $1,035.65 | $2,060.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.28 / $1,001.63 / $1,312.37
| Professional | | $602.28 | $1,001.63 | $1,312.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.95 / $896.34 / $1,312.37
| Professional | | $607.95 | $896.34 | $1,312.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.31 / $824.28 / $2,396.23
| Professional | | $779.31 | $824.28 | $2,396.23 |