- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.28 / $311.76 / $1,227.17
| Professional | | $201.28 | $311.76 | $1,227.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.73 / $1,090.73 / $1,090.73
| Professional | | $1,090.73 | $1,090.73 | $1,090.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.32 / $376.15 / $1,090.73
| Professional | | $238.32 | $376.15 | $1,090.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.86 / $453.76 / $1,090.73
| Professional | | $309.86 | $453.76 | $1,090.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.98 / $508.17 / $1,338.75
| Professional | | $375.98 | $508.17 | $1,338.75 |