- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.95 / $358.81 / $1,240.00
| Professional | | $173.95 | $358.81 | $1,240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $665.00 / $750.13 / $1,194.52
| Professional | | $665.00 | $750.13 | $1,194.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.44 / $350.19 / $1,194.52
| Professional | | $192.44 | $350.19 | $1,194.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.69 / $374.76 / $1,194.52
| Professional | | $225.69 | $374.76 | $1,194.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.28 / $474.37 / $1,466.15
| Professional | | $434.28 | $474.37 | $1,466.15 |