- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.59 / $402.24 / $1,530.50
| Professional | | $227.59 | $402.24 | $1,530.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.71 / $1,800.83 / $4,590.53
| Professional | | $1,527.71 | $1,800.83 | $4,590.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.32 / $681.99 / $3,067.00
| Professional | | $359.32 | $681.99 | $3,067.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $359.32 / $528.97 / $3,373.23
| Professional | | $359.32 | $528.97 | $3,373.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.26 / $1,926.33 / $5,634.36
| Professional | | $1,378.26 | $1,926.33 | $5,634.36 |