- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.12 / $397.64 / $683.64
| Professional | | $271.12 | $397.64 | $683.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.49 / $397.52 / $833.94
| Professional | | $254.49 | $397.52 | $833.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $276.49 / $529.25 / $1,005.60
| Professional | | $276.49 | $529.25 | $1,005.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,252.00 / $4,446.43 / $4,446.43
| Professional | | $3,252.00 | $4,446.43 | $4,446.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.99 / $548.12 / $1,029.15
| Professional | | $304.99 | $548.12 | $1,029.15 |