- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $691.83 / $4,570.88
| Professional | | $177.83 | $691.83 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $3,548.13 / $7,585.78
| Professional | | $229.09 | $3,548.13 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $3,467.37 / $6,918.31
| Professional | | $199.53 | $3,467.37 | $6,918.31 |