- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.52 / $298.43 / $1,821.34
| Professional | | $123.52 | $298.43 | $1,821.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.94 / $1,298.94 / $1,298.94
| Professional | | $1,298.94 | $1,298.94 | $1,298.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.99 / $278.47 / $1,298.94
| Professional | | $118.99 | $278.47 | $1,298.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.72 / $376.21 / $1,298.94
| Professional | | $146.72 | $376.21 | $1,298.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.73 / $482.85 / $1,594.31
| Professional | | $298.73 | $482.85 | $1,594.31 |