- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,445.44 / $3,235.94
| Professional | | $371.54 | $1,445.44 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $851.14 / $2,290.87
| Professional | | $346.74 | $851.14 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $1,778.28 / $3,235.94
| Professional | | $489.78 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,778.28 / $2,754.23
| Professional | | $407.38 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,698.24 / $3,890.45
| Professional | | $446.68 | $1,698.24 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,258.93 / $3,388.44
| Professional | | $501.19 | $1,258.93 | $3,388.44 |