- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,545.87
| Professional | | $2,396.11 | $2,485.96 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.02 / $2,545.87 / $2,545.87
| Professional | | $378.02 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $357.36 / $357.36 / $357.36
| Professional | | $357.36 | $357.36 | $357.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.49 / $2,495.94 / $3,743.93
| Professional | | $343.49 | $2,495.94 | $3,743.93 |