- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.12 / $310.41 / $1,240.32
| Professional | | $209.12 | $310.41 | $1,240.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.00 / $819.25 / $2,318.07
| Professional | | $695.00 | $819.25 | $2,318.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.81 / $510.34 / $2,318.07
| Professional | | $289.81 | $510.34 | $2,318.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.60 / $679.92 / $2,318.07
| Professional | | $318.60 | $679.92 | $2,318.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.47 / $942.05 / $2,845.17
| Professional | | $362.47 | $942.05 | $2,845.17 |