- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.27 / $897.52 / $897.52
| Professional | | $752.27 | $897.52 | $897.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.83 / $1,055.83 / $2,698.05
| Professional | | $1,055.83 | $1,055.83 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.55 / $1,290.41 / $1,682.08
| Professional | | $824.55 | $1,290.41 | $1,682.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.08 / $1,116.42 / $1,682.08
| Professional | | $779.08 | $1,116.42 | $1,682.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.31 / $1,039.29 / $3,071.31
| Professional | | $915.31 | $1,039.29 | $3,071.31 |