- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.25 / $551.39 / $963.53
| Professional | | $399.25 | $551.39 | $963.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.70 / $775.47 / $2,376.35
| Professional | | $638.70 | $775.47 | $2,376.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.66 / $745.03 / $1,687.00
| Professional | | $518.66 | $745.03 | $1,687.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.37 / $773.29 / $1,687.00
| Professional | | $544.37 | $773.29 | $1,687.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.32 / $665.06 / $2,136.98
| Professional | | $551.32 | $665.06 | $2,136.98 |