- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $1,230.27
| Professional | | $1,148.15 | $1,202.26 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $562.34 / $645.65
| Professional | | $478.63 | $562.34 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $138.04 / $141.25
| Professional | | $138.04 | $138.04 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,202.26 / $1,202.26
| Professional | | $1,071.52 | $1,202.26 | $1,202.26 |