- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.62 / $461.79 / $644.67
| Professional | | $329.62 | $461.79 | $644.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,892.15 / $1,892.15 / $1,892.15
| Professional | | $1,892.15 | $1,892.15 | $1,892.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.79 / $698.51 / $1,216.71
| Professional | | $483.79 | $698.51 | $1,216.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.82 / $744.28 / $1,216.71
| Professional | | $512.82 | $744.28 | $1,216.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.35 / $764.20 / $2,221.60
| Professional | | $607.35 | $764.20 | $2,221.60 |