- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.78 / $388.08 / $488.15
| Professional | | $177.78 | $388.08 | $488.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.05 / $774.69 / $1,898.41
| Professional | | $638.05 | $774.69 | $1,898.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.64 / $429.10 / $1,147.46
| Professional | | $186.64 | $429.10 | $1,147.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.81 / $491.86 / $1,147.46
| Professional | | $250.81 | $491.86 | $1,147.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.09 / $529.23 / $1,577.90
| Professional | | $407.09 | $529.23 | $1,577.90 |