- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.00 / $425.00 / $425.00
| Professional | | $375.00 | $425.00 | $425.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $535.62 / $631.38 / $1,483.59
| Professional | | $535.62 | $631.38 | $1,483.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.64 / $835.45 / $1,483.59
| Professional | | $503.64 | $835.45 | $1,483.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $503.64 / $802.78 / $1,483.59
| Professional | | $503.64 | $802.78 | $1,483.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.83 / $768.21 / $1,489.80
| Professional | | $410.83 | $768.21 | $1,489.80 |