- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.06 / $347.75 / $504.25
| Professional | | $247.06 | $347.75 | $504.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.78 / $636.77 / $1,879.32
| Professional | | $524.78 | $636.77 | $1,879.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $592.51 / $1,133.98
| Professional | | $308.68 | $592.51 | $1,133.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.68 / $644.07 / $1,133.98
| Professional | | $308.68 | $644.07 | $1,133.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.12 / $692.80 / $2,070.52
| Professional | | $313.12 | $692.80 | $2,070.52 |