- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.93 / $601.51 / $2,325.91
| Professional | | $438.93 | $601.51 | $2,325.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.98 / $1,066.78 / $2,176.88
| Professional | | $904.98 | $1,066.78 | $2,176.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.58 / $762.03 / $1,047.58
| Professional | | $472.58 | $762.03 | $1,047.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.58 / $736.34 / $1,047.58
| Professional | | $472.58 | $736.34 | $1,047.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $713.66 / $813.16 / $2,463.84
| Professional | | $713.66 | $813.16 | $2,463.84 |