- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $223.87 / $416.87
| Professional | | $141.25 | $223.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $416.87 / $758.58
| Professional | | $251.19 | $416.87 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $575.44 / $1,000.00
| Professional | | $331.13 | $575.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $501.19 / $912.01
| Professional | | $323.59 | $501.19 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $602.56 / $1,659.59
| Professional | | $295.12 | $602.56 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $446.68 / $933.25
| Professional | | $229.09 | $446.68 | $933.25 |