- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.01 / $466.52 / $466.52
| Professional | | $407.01 | $466.52 | $466.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.34 / $1,284.34 / $1,284.34
| Professional | | $1,284.34 | $1,284.34 | $1,284.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.21 / $615.39 / $1,284.34
| Professional | | $521.21 | $615.39 | $1,284.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.21 / $615.39 / $1,284.34
| Professional | | $521.21 | $615.39 | $1,284.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.91 / $558.22 / $1,576.40
| Professional | | $491.91 | $558.22 | $1,576.40 |