- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.74 / $179.90 / $2,875.20
| Professional | | $158.74 | $179.90 | $2,875.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $574.52 / $677.23 / $1,829.83
| Professional | | $574.52 | $677.23 | $1,829.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.95 / $403.02 / $1,829.83
| Professional | | $172.95 | $403.02 | $1,829.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.00 / $456.02 / $1,829.83
| Professional | | $192.00 | $456.02 | $1,829.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.66 / $747.34 / $2,245.91
| Professional | | $209.66 | $747.34 | $2,245.91 |