- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.06 / $598.03 / $801.32
| Professional | | $428.06 | $598.03 | $801.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.01 / $1,065.63 / $2,441.15
| Professional | | $904.01 | $1,065.63 | $2,441.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $652.09 / $913.95 / $1,523.87
| Professional | | $652.09 | $913.95 | $1,523.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.04 / $913.95 / $1,523.87
| Professional | | $676.04 | $913.95 | $1,523.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.26 / $957.12 / $2,782.43
| Professional | | $806.26 | $957.12 | $2,782.43 |