- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.46 / $354.43 / $1,322.19
| Professional | | $241.46 | $354.43 | $1,322.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.93 / $337.93 / $1,207.25
| Professional | | $337.93 | $337.93 | $1,207.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.69 / $454.20 / $1,207.25
| Professional | | $225.69 | $454.20 | $1,207.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.33 / $543.54 / $1,207.25
| Professional | | $347.33 | $543.54 | $1,207.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.89 / $472.96 / $1,481.76
| Professional | | $382.89 | $472.96 | $1,481.76 |