- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $416.87 / $1,000.00
| Professional | | $316.23 | $416.87 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $512.86 / $812.83
| Professional | | $302.00 | $512.86 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $512.86 / $758.58
| Professional | | $389.05 | $512.86 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $467.74 / $851.14
| Professional | | $380.19 | $467.74 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $467.74 / $1,096.48
| Professional | | $331.13 | $467.74 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $478.63 / $758.58
| Professional | | $323.59 | $478.63 | $758.58 |