- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.09 / $243.01 / $1,016.00
| Professional | | $129.09 | $243.01 | $1,016.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.15 / $278.37 / $779.86
| Professional | | $236.15 | $278.37 | $779.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.80 / $256.76 / $779.86
| Professional | | $146.80 | $256.76 | $779.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.13 / $266.47 / $779.86
| Professional | | $159.13 | $266.47 | $779.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.42 / $284.64 / $957.20
| Professional | | $257.42 | $284.64 | $957.20 |