- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $1,148.15
| Professional | | $389.05 | $512.86 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $562.34
| Professional | | $467.74 | $467.74 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $616.60 / $1,000.00
| Professional | | $323.59 | $616.60 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $616.60 / $758.58
| Professional | | $457.09 | $616.60 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $630.96 / $1,819.70
| Professional | | $478.63 | $630.96 | $1,819.70 |