- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.21 / $735.73 / $3,288.74
| Professional | | $522.21 | $735.73 | $3,288.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.60 / $743.60 / $2,380.14
| Professional | | $743.60 | $743.60 | $2,380.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.15 / $732.92 / $2,380.14
| Professional | | $376.15 | $732.92 | $2,380.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.80 / $970.51 / $2,380.14
| Professional | | $662.80 | $970.51 | $2,380.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.41 / $877.37 / $2,921.36
| Professional | | $627.41 | $877.37 | $2,921.36 |