- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.87 / $624.99 / $1,001.97
| Professional | | $543.87 | $624.99 | $1,001.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.61 / $812.59 / $1,252.54
| Professional | | $587.61 | $812.59 | $1,252.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.10 / $790.12 / $1,381.65
| Professional | | $501.10 | $790.12 | $1,381.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,283.07 / $4,283.07 / $4,283.07
| Professional | | $4,283.07 | $4,283.07 | $4,283.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $578.35 / $717.68 / $1,258.86
| Professional | | $578.35 | $717.68 | $1,258.86 |