- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.05 / $418.43 / $526.54
| Professional | | $192.05 | $418.43 | $526.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $667.06 / $809.91 / $1,898.41
| Professional | | $667.06 | $809.91 | $1,898.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.96 / $447.72 / $1,196.73
| Professional | | $201.96 | $447.72 | $1,196.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.51 / $532.26 / $1,196.73
| Professional | | $270.51 | $532.26 | $1,196.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.63 / $567.50 / $1,649.77
| Professional | | $425.63 | $567.50 | $1,649.77 |