- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.40 / $1,058.40 / $1,058.40
| Professional | | $1,058.40 | $1,058.40 | $1,058.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.26 / $1,105.78 / $1,105.78
| Professional | | $846.26 | $1,105.78 | $1,105.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.95 / $1,232.30 / $1,232.30
| Professional | | $124.95 | $1,232.30 | $1,232.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.67 / $631.67 / $1,058.40
| Professional | | $631.67 | $631.67 | $1,058.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.76 / $743.64 / $1,910.23
| Professional | | $495.76 | $743.64 | $1,910.23 |