- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.06 / $368.70 / $507.87
| Professional | | $202.06 | $368.70 | $507.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $601.64 / $601.64 / $1,427.81
| Professional | | $601.64 | $601.64 | $1,427.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.60 / $443.93 / $924.45
| Professional | | $260.60 | $443.93 | $924.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.77 / $551.97 / $924.45
| Professional | | $260.77 | $551.97 | $924.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.02 / $580.64 / $1,687.95
| Professional | | $531.02 | $580.64 | $1,687.95 |