- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $208.93 / $363.08
| Professional | | $131.83 | $208.93 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $416.87 / $776.25
| Professional | | $245.47 | $416.87 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $588.84 / $1,000.00
| Professional | | $323.59 | $588.84 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $512.86 / $933.25
| Professional | | $323.59 | $512.86 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $501.19 / $1,348.96
| Professional | | $281.84 | $501.19 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $398.11 / $794.33
| Professional | | $199.53 | $398.11 | $794.33 |