- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.06 / $301.38 / $1,214.27
| Professional | | $193.06 | $301.38 | $1,214.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $428.47 / $428.47 / $1,282.74
| Professional | | $428.47 | $428.47 | $1,282.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $458.35 / $1,282.74
| Professional | | $240.00 | $458.35 | $1,282.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.07 / $463.23 / $1,282.74
| Professional | | $313.07 | $463.23 | $1,282.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.02 / $491.29 / $1,574.42
| Professional | | $380.02 | $491.29 | $1,574.42 |