- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.04 / $829.44 / $3,476.49
| Professional | | $577.04 | $829.44 | $3,476.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.97 / $956.97 / $2,385.57
| Professional | | $956.97 | $956.97 | $2,385.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.75 / $1,115.14 / $2,385.57
| Professional | | $670.75 | $1,115.14 | $2,385.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.19 / $1,117.46 / $2,385.57
| Professional | | $852.19 | $1,117.46 | $2,385.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.24 / $934.75 / $2,928.02
| Professional | | $790.24 | $934.75 | $2,928.02 |