- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $389.05 / $1,548.82
| Professional | | $257.04 | $389.05 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $489.78 / $724.44
| Professional | | $302.00 | $489.78 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $758.58 / $1,148.15
| Professional | | $416.87 | $758.58 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $741.31 / $2,884.03
| Professional | | $436.52 | $741.31 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,122.02
| Professional | | $602.56 | $831.76 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $851.14 / $1,202.26
| Professional | | $616.60 | $851.14 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $562.34 / $912.01
| Professional | | $331.13 | $562.34 | $912.01 |