- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.74 / $884.74 / $884.74
| Professional | | $884.74 | $884.74 | $884.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.98 / $1,022.92 / $1,022.92
| Professional | | $887.98 | $1,022.92 | $1,022.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.61 / $115.61 / $1,140.20
| Professional | | $115.61 | $115.61 | $1,140.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.64 / $598.64 / $884.74
| Professional | | $598.64 | $598.64 | $884.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.83 / $688.24 / $1,767.57
| Professional | | $458.83 | $688.24 | $1,767.57 |