- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.06 / $357.18 / $1,771.49
| Professional | | $211.06 | $357.18 | $1,771.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.54 / $406.54 / $1,187.78
| Professional | | $406.54 | $406.54 | $1,187.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.69 / $441.90 / $1,187.78
| Professional | | $225.69 | $441.90 | $1,187.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.39 / $495.58 / $1,187.78
| Professional | | $301.39 | $495.58 | $1,187.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.00 / $472.71 / $1,457.87
| Professional | | $403.00 | $472.71 | $1,457.87 |