- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $588.84 / $954.99
| Professional | | $398.11 | $588.84 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,380.38
| Professional | | $758.58 | $1,023.29 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $954.99 / $1,621.81
| Professional | | $416.87 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $977.24 / $3,630.78
| Professional | | $537.03 | $977.24 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $758.58 / $1,230.27
| Professional | | $478.63 | $758.58 | $1,230.27 |