- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.67 / $762.40 / $762.40
| Professional | | $407.67 | $762.40 | $762.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $521.61 / $521.61 / $1,211.32
| Professional | | $521.61 | $521.61 | $1,211.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.32 / $704.34 / $1,098.03
| Professional | | $449.32 | $704.34 | $1,098.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.43 / $709.51 / $1,098.03
| Professional | | $453.43 | $709.51 | $1,098.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.58 / $763.33 / $1,423.16
| Professional | | $481.58 | $763.33 | $1,423.16 |