- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.30 / $461.37 / $2,427.40
| Professional | | $301.30 | $461.37 | $2,427.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.86 / $474.86 / $1,705.54
| Professional | | $474.86 | $474.86 | $1,705.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.31 / $601.74 / $1,705.54
| Professional | | $358.31 | $601.74 | $1,705.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.01 / $738.55 / $1,705.54
| Professional | | $453.01 | $738.55 | $1,705.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.46 / $647.72 / $2,093.36
| Professional | | $573.46 | $647.72 | $2,093.36 |