- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.74 / $311.00 / $1,243.26
| Professional | | $193.74 | $311.00 | $1,243.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.97 / $388.72 / $623.88
| Professional | | $206.97 | $388.72 | $623.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $635.08 / $1,033.45
| Professional | | $318.22 | $635.08 | $1,033.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.78 / $801.29 / $2,492.96
| Professional | | $454.78 | $801.29 | $2,492.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $465.80 / $650.42 / $972.64
| Professional | | $465.80 | $650.42 | $972.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.78 / $801.29 / $876.72
| Professional | | $454.78 | $801.29 | $876.72 |