- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.60 / $630.04 / $967.36
| Professional | | $518.60 | $630.04 | $967.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,588.96 / $2,588.96 / $2,588.96
| Professional | | $2,588.96 | $2,588.96 | $2,588.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.30 / $1,111.96 / $2,588.96
| Professional | | $672.30 | $1,111.96 | $2,588.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.30 / $1,111.96 / $2,588.96
| Professional | | $672.30 | $1,111.96 | $2,588.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.27 / $953.83 / $2,772.86
| Professional | | $799.27 | $953.83 | $2,772.86 |