- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.77 / $539.28 / $2,637.71
| Professional | | $420.77 | $539.28 | $2,637.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.32 / $585.32 / $1,983.63
| Professional | | $585.32 | $585.32 | $1,983.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.52 / $959.15 / $1,983.63
| Professional | | $446.52 | $959.15 | $1,983.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $679.89 / $959.15 / $1,983.63
| Professional | | $679.89 | $959.15 | $1,983.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.23 / $706.90 / $2,434.67
| Professional | | $587.23 | $706.90 | $2,434.67 |