- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.85 / $906.85 / $906.85
| Professional | | $906.85 | $906.85 | $906.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $948.15 / $1,274.85 / $1,522.24
| Professional | | $948.15 | $1,274.85 | $1,522.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.33 / $773.33 / $773.33
| Professional | | $773.33 | $773.33 | $773.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.46 / $1,087.61 / $6,302.04
| Professional | | $855.46 | $1,087.61 | $6,302.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.59 / $1,087.61 / $1,604.00
| Professional | | $840.59 | $1,087.61 | $1,604.00 |