- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $467.74 / $1,202.26
| Professional | | $302.00 | $467.74 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $1,737.80
| Professional | | $602.56 | $602.56 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $602.56 / $870.96
| Professional | | $346.74 | $602.56 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $676.08 / $794.33
| Professional | | $501.19 | $676.08 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $575.44 / $1,174.90
| Professional | | $436.52 | $575.44 | $1,174.90 |