- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.97 / $823.03 / $823.03
| Professional | | $737.97 | $823.03 | $823.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.80 / $961.80 / $961.80
| Professional | | $961.80 | $961.80 | $961.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.05 / $130.25 / $1,223.23
| Professional | | $124.05 | $130.25 | $1,223.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.89 / $738.61 / $1,024.24
| Professional | | $491.89 | $738.61 | $1,024.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,171.98 / $1,298.53 / $1,652.67
| Professional | | $1,171.98 | $1,298.53 | $1,652.67 |