- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $275.42 / $1,230.27
| Professional | | $79.43 | $275.42 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $660.69 / $1,698.24
| Professional | | $125.89 | $660.69 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $794.33 / $1,698.24
| Professional | | $114.82 | $794.33 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,318.26
| Professional | | $1,202.26 | $1,202.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.10 / $446.68 / $1,698.24
| Professional | | $87.10 | $446.68 | $1,698.24 |