- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $588.84 / $1,023.29
| Professional | | $380.19 | $588.84 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $602.56 / $1,202.26
| Professional | | $389.05 | $602.56 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $602.56 / $1,174.90
| Professional | | $371.54 | $602.56 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $512.86 / $1,047.13
| Professional | | $354.81 | $512.86 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $4,570.88 / $5,011.87
| Professional | | $4,570.88 | $4,570.88 | $5,011.87 |