- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.46 / $795.65 / $5,313.42
| Professional | | $159.46 | $795.65 | $5,313.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,635.31 / $1,860.00 / $1,860.00
| Professional | | $1,635.31 | $1,860.00 | $1,860.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.59 / $1,302.02 / $2,788.93
| Professional | | $192.59 | $1,302.02 | $2,788.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.79 / $1,826.49 / $3,443.02
| Professional | | $1,268.79 | $1,826.49 | $3,443.02 |