- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.47 / $740.88 / $1,210.83
| Professional | | $518.47 | $740.88 | $1,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.36 / $934.01 / $2,712.57
| Professional | | $792.36 | $934.01 | $2,712.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.66 / $946.28 / $1,297.42
| Professional | | $545.66 | $946.28 | $1,297.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $901.36 / $1,297.42
| Professional | | $525.00 | $901.36 | $1,297.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.87 / $899.65 / $3,051.08
| Professional | | $715.87 | $899.65 | $3,051.08 |