- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.02 / $896.62 / $1,237.33
| Professional | | $518.02 | $896.62 | $1,237.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.91 / $1,041.91 / $1,041.91
| Professional | | $1,041.91 | $1,041.91 | $1,041.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.45 / $293.45 / $293.45
| Professional | | $293.45 | $293.45 | $293.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.49 / $809.46 / $1,103.81
| Professional | | $625.49 | $809.46 | $1,103.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.11 / $1,150.88 / $1,773.25
| Professional | | $467.11 | $1,150.88 | $1,773.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $608.49 / $608.49 / $608.49
| Professional | | $608.49 | $608.49 | $608.49 |