- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.25 / $382.52 / $520.16
| Professional | | $292.25 | $382.52 | $520.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.48 / $479.94 / $752.02
| Professional | | $333.48 | $479.94 | $752.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.53 / $492.44 / $1,040.40
| Professional | | $343.53 | $492.44 | $1,040.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,624.00 / $3,444.72 / $4,018.80
| Professional | | $2,624.00 | $3,444.72 | $4,018.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.42 / $516.87 / $967.14
| Professional | | $418.42 | $516.87 | $967.14 |