- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.97 / $271.66 / $1,119.00
| Professional | | $172.97 | $271.66 | $1,119.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.57 / $352.20 / $1,038.96
| Professional | | $295.57 | $352.20 | $1,038.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.84 / $388.60 / $1,038.96
| Professional | | $207.84 | $388.60 | $1,038.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.08 / $389.66 / $1,038.96
| Professional | | $263.08 | $389.66 | $1,038.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.27 / $391.44 / $1,275.21
| Professional | | $266.27 | $391.44 | $1,275.21 |