- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.30 / $298.20 / $1,490.07
| Professional | | $183.30 | $298.20 | $1,490.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.94 / $1,015.94 / $1,015.94
| Professional | | $1,015.94 | $1,015.94 | $1,015.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.74 / $297.38 / $1,015.94
| Professional | | $186.74 | $297.38 | $1,015.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.28 / $407.93 / $1,015.94
| Professional | | $199.28 | $407.93 | $1,015.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.23 / $396.10 / $1,246.95
| Professional | | $310.23 | $396.10 | $1,246.95 |