- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.67 / $334.20 / $1,097.00
| Professional | | $179.67 | $334.20 | $1,097.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.77 / $590.29 / $1,164.24
| Professional | | $500.77 | $590.29 | $1,164.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.42 / $334.70 / $1,164.24
| Professional | | $191.42 | $334.70 | $1,164.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.69 / $339.96 / $1,164.24
| Professional | | $225.69 | $339.96 | $1,164.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.47 / $412.65 / $1,428.98
| Professional | | $362.47 | $412.65 | $1,428.98 |