- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.83 / $609.26 / $1,126.26
| Professional | | $463.83 | $609.26 | $1,126.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.84 / $969.91 / $2,972.15
| Professional | | $798.84 | $969.91 | $2,972.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.45 / $827.50 / $1,865.30
| Professional | | $591.45 | $827.50 | $1,865.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.99 / $861.10 / $1,865.30
| Professional | | $616.99 | $861.10 | $1,865.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.92 / $761.97 / $2,391.51
| Professional | | $597.92 | $761.97 | $2,391.51 |