- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.31 / $429.83 / $1,763.82
| Professional | | $292.31 | $429.83 | $1,763.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.50 / $498.50 / $1,741.28
| Professional | | $498.50 | $498.50 | $1,741.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.80 / $644.16 / $1,741.28
| Professional | | $335.80 | $644.16 | $1,741.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.02 / $662.71 / $1,741.28
| Professional | | $416.02 | $662.71 | $1,741.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.06 / $660.02 / $2,137.23
| Professional | | $406.06 | $660.02 | $2,137.23 |