- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.51 / $768.08 / $768.08
| Professional | | $627.51 | $768.08 | $768.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.35 / $1,072.35 / $1,072.35
| Professional | | $1,072.35 | $1,072.35 | $1,072.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.40 / $894.40 / $894.40
| Professional | | $894.40 | $894.40 | $894.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.32 / $733.98 / $1,209.18
| Professional | | $489.32 | $733.98 | $1,209.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,114.49 / $1,234.83 / $1,571.61
| Professional | | $1,114.49 | $1,234.83 | $1,571.61 |