- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $478.63 / $812.83
| Professional | | $331.13 | $478.63 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,047.13 / $1,819.70
| Professional | | $645.65 | $1,047.13 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $2,290.87
| Professional | | $794.33 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,137.96
| Professional | | $812.83 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $1,047.13 / $2,951.21
| Professional | | $524.81 | $1,047.13 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $776.25 / $1,584.89
| Professional | | $426.58 | $776.25 | $1,584.89 |