- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.55 / $567.33 / $2,384.42
| Professional | | $371.55 | $567.33 | $2,384.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.52 / $610.52 / $2,039.39
| Professional | | $610.52 | $610.52 | $2,039.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.71 / $786.78 / $2,039.39
| Professional | | $393.71 | $786.78 | $2,039.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.32 / $891.38 / $2,039.39
| Professional | | $624.32 | $891.38 | $2,039.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.51 / $780.07 / $2,503.13
| Professional | | $624.51 | $780.07 | $2,503.13 |