- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $1,063.42
| Professional | | $1,052.89 | $1,052.89 | $1,063.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.18 / $360.22 / $1,052.89
| Professional | | $306.18 | $360.22 | $1,052.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.52 / $438.26 / $504.00
| Professional | | $372.52 | $438.26 | $504.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.18 / $1,263.46 / $1,474.04
| Professional | | $1,158.18 | $1,263.46 | $1,474.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.18 / $1,052.89 / $1,579.34
| Professional | | $306.18 | $1,052.89 | $1,579.34 |