- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.34 / $478.23 / $2,466.69
| Professional | | $455.34 | $478.23 | $2,466.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $587.54 / $587.54 / $1,705.76
| Professional | | $587.54 | $587.54 | $1,705.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $405.98 / $798.65 / $1,705.76
| Professional | | $405.98 | $798.65 | $1,705.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.96 / $758.78 / $1,705.76
| Professional | | $490.96 | $758.78 | $1,705.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.06 / $662.59 / $2,093.63
| Professional | | $496.06 | $662.59 | $2,093.63 |