- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.87 / $338.20 / $1,892.25
| Professional | | $162.87 | $338.20 | $1,892.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.70 / $1,376.70 / $1,376.70
| Professional | | $1,376.70 | $1,376.70 | $1,376.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.83 / $310.77 / $1,376.70
| Professional | | $182.83 | $310.77 | $1,376.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.83 / $484.50 / $1,376.70
| Professional | | $193.83 | $484.50 | $1,376.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.32 / $479.64 / $1,689.75
| Professional | | $323.32 | $479.64 | $1,689.75 |