- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.87 / $469.17 / $947.15
| Professional | | $167.87 | $469.17 | $947.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $648.52 / $648.52 / $2,028.06
| Professional | | $648.52 | $648.52 | $2,028.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.12 / $464.02 / $2,028.06
| Professional | | $241.12 | $464.02 | $2,028.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.71 / $743.32 / $2,028.06
| Professional | | $252.71 | $743.32 | $2,028.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.16 / $773.12 / $2,489.21
| Professional | | $598.16 | $773.12 | $2,489.21 |