- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.11 / $236.74 / $1,255.00
| Professional | | $145.11 | $236.74 | $1,255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.51 / $345.99 / $967.62
| Professional | | $293.51 | $345.99 | $967.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.49 / $327.60 / $967.62
| Professional | | $201.49 | $327.60 | $967.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.03 / $356.93 / $967.62
| Professional | | $216.03 | $356.93 | $967.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.33 / $363.13 / $1,055.65
| Professional | | $270.33 | $363.13 | $1,055.65 |