- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $562.34 / $954.99
| Professional | | $371.54 | $562.34 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $630.96 / $1,071.52
| Professional | | $426.58 | $630.96 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $575.44 / $1,000.00
| Professional | | $380.19 | $575.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,011.87 / $5,011.87
| Professional | | $4,570.88 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $549.54 / $933.25
| Professional | | $371.54 | $549.54 | $933.25 |