- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.03 / $510.75 / $1,609.00
| Professional | | $388.03 | $510.75 | $1,609.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $621.67 / $621.67 / $732.83
| Professional | | $621.67 | $621.67 | $732.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.10 / $478.81 / $1,588.03
| Professional | | $290.10 | $478.81 | $1,588.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.07 / $617.15 / $1,588.03
| Professional | | $397.07 | $617.15 | $1,588.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.85 / $590.02 / $1,949.13
| Professional | | $531.85 | $590.02 | $1,949.13 |