- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.36 / $423.27 / $1,953.52
| Professional | | $277.36 | $423.27 | $1,953.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,946.77 / $2,294.81 / $5,685.77
| Professional | | $1,946.77 | $2,294.81 | $5,685.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.58 / $1,600.00 / $4,108.07
| Professional | | $474.58 | $1,600.00 | $4,108.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.85 / $2,091.31 / $3,498.29
| Professional | | $508.85 | $2,091.31 | $3,498.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,081.08 / $2,490.55 / $6,978.65
| Professional | | $2,081.08 | $2,490.55 | $6,978.65 |