- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.96 / $309.06 / $1,480.00
| Professional | | $176.96 | $309.06 | $1,480.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.14 / $347.14 / $1,035.36
| Professional | | $347.14 | $347.14 | $1,035.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.91 / $376.15 / $1,035.36
| Professional | | $217.91 | $376.15 | $1,035.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.88 / $420.24 / $1,035.36
| Professional | | $277.88 | $420.24 | $1,035.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.66 / $410.56 / $1,270.80
| Professional | | $320.66 | $410.56 | $1,270.80 |