- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.43 / $244.18 / $810.00
| Professional | | $169.43 | $244.18 | $810.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.05 / $690.84 / $1,521.05
| Professional | | $586.05 | $690.84 | $1,521.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.24 / $376.15 / $1,521.05
| Professional | | $238.24 | $376.15 | $1,521.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.46 / $581.91 / $1,521.05
| Professional | | $241.46 | $581.91 | $1,521.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.36 / $555.73 / $1,866.92
| Professional | | $247.36 | $555.73 | $1,866.92 |