- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.37 / $570.89 / $1,088.73
| Professional | | $387.37 | $570.89 | $1,088.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $714.67 / $842.44 / $2,443.67
| Professional | | $714.67 | $842.44 | $2,443.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.63 / $839.87 / $1,167.16
| Professional | | $488.63 | $839.87 | $1,167.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.63 / $799.84 / $1,167.16
| Professional | | $488.63 | $799.84 | $1,167.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.57 / $812.28 / $2,751.98
| Professional | | $724.57 | $812.28 | $2,751.98 |