- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.29 / $642.29 / $685.32
| Professional | | $642.29 | $642.29 | $685.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.73 / $1,555.73 / $1,555.73
| Professional | | $1,555.73 | $1,555.73 | $1,555.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.53 / $803.91 / $1,353.08
| Professional | | $662.53 | $803.91 | $1,353.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $700.44 / $823.19 / $1,555.73
| Professional | | $700.44 | $823.19 | $1,555.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.72 / $542.86 / $1,666.22
| Professional | | $372.72 | $542.86 | $1,666.22 |