- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.03 / $718.35 / $718.35
| Professional | | $622.03 | $718.35 | $718.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.48 / $2,563.48 / $2,563.48
| Professional | | $2,563.48 | $2,563.48 | $2,563.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.18 / $1,224.27 / $2,563.48
| Professional | | $902.18 | $1,224.27 | $2,563.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.18 / $1,224.27 / $2,563.48
| Professional | | $902.18 | $1,224.27 | $2,563.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.25 / $989.58 / $3,146.40
| Professional | | $753.25 | $989.58 | $3,146.40 |