- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.97 / $654.23 / $1,888.00
| Professional | | $387.97 | $654.23 | $1,888.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.21 / $436.21 / $1,556.10
| Professional | | $436.21 | $436.21 | $1,556.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.41 / $778.53 / $1,556.10
| Professional | | $446.41 | $778.53 | $1,556.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.69 / $778.53 / $1,556.10
| Professional | | $598.69 | $778.53 | $1,556.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.95 / $613.61 / $1,909.94
| Professional | | $594.95 | $613.61 | $1,909.94 |