- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.27 / $229.18 / $1,896.00
| Professional | | $46.27 | $229.18 | $1,896.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.46 / $470.46 / $1,136.74
| Professional | | $470.46 | $470.46 | $1,136.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.46 / $262.98 / $1,136.74
| Professional | | $60.46 | $262.98 | $1,136.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.18 / $504.98 / $1,136.74
| Professional | | $71.18 | $504.98 | $1,136.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.13 / $586.30 / $1,395.23
| Professional | | $506.13 | $586.30 | $1,395.23 |