- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.02 / $284.07 / $451.09
| Professional | | $207.02 | $284.07 | $451.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.81 / $544.61 / $774.33
| Professional | | $420.81 | $544.61 | $774.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.00 / $602.09 / $1,061.20
| Professional | | $401.00 | $602.09 | $1,061.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.62 / $791.32 / $2,492.96
| Professional | | $396.62 | $791.32 | $2,492.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.62 / $654.41 / $1,028.79
| Professional | | $396.62 | $654.41 | $1,028.79 |