- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $398.11 / $1,023.29
| Professional | | $288.40 | $398.11 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $398.11 / $1,230.27
| Professional | | $398.11 | $398.11 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $457.09 / $676.08
| Professional | | $295.12 | $457.09 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $575.44
| Professional | | $346.74 | $467.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $436.52 / $812.83
| Professional | | $354.81 | $436.52 | $812.83 |