- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.28 / $459.56 / $2,152.00
| Professional | | $248.28 | $459.56 | $2,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $518.38 / $611.04 / $1,706.45
| Professional | | $518.38 | $611.04 | $1,706.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.72 / $617.16 / $1,706.45
| Professional | | $263.72 | $617.16 | $1,706.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.57 / $692.17 / $1,706.45
| Professional | | $417.57 | $692.17 | $1,706.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.19 / $669.52 / $2,094.48
| Professional | | $519.19 | $669.52 | $2,094.48 |