- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $629.16 / $774.33 / $3,460.85
| Professional | | $629.16 | $774.33 | $3,460.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.59 / $936.43 / $2,819.81
| Professional | | $790.59 | $936.43 | $2,819.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.23 / $1,087.17 / $1,357.67
| Professional | | $661.23 | $1,087.17 | $1,357.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.23 / $1,071.38 / $1,357.67
| Professional | | $661.23 | $1,071.38 | $1,357.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.40 / $963.52 / $3,195.73
| Professional | | $831.40 | $963.52 | $3,195.73 |