- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.83 / $522.15 / $2,074.00
| Professional | | $344.83 | $522.15 | $2,074.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.65 / $542.65 / $655.39
| Professional | | $542.65 | $542.65 | $655.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $425.75 / $532.32 / $1,972.88
| Professional | | $425.75 | $532.32 | $1,972.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.36 / $510.30 / $1,972.88
| Professional | | $382.36 | $510.30 | $1,972.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.79 / $651.79 / $2,421.50
| Professional | | $543.79 | $651.79 | $2,421.50 |