- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $398.11 / $616.60
| Professional | | $281.84 | $398.11 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $1,445.44
| Professional | | $512.86 | $512.86 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $512.86 / $1,445.44
| Professional | | $295.12 | $512.86 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $562.34 / $1,000.00
| Professional | | $407.38 | $562.34 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $446.68 / $870.96
| Professional | | $316.23 | $446.68 | $870.96 |