- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $562.34 / $1,380.38
| Professional | | $416.87 | $562.34 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $851.14
| Professional | | $676.08 | $676.08 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $724.44 / $912.01
| Professional | | $457.09 | $724.44 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $912.01 / $1,000.00
| Professional | | $724.44 | $912.01 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $676.08 / $977.24
| Professional | | $79.43 | $676.08 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $794.33 / $1,000.00
| Professional | | $645.65 | $794.33 | $1,000.00 |