- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.54 / $449.84 / $1,783.20
| Professional | | $84.54 | $449.84 | $1,783.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.82 / $1,707.82 / $3,539.69
| Professional | | $1,707.82 | $1,707.82 | $3,539.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.08 / $827.42 / $3,539.69
| Professional | | $134.08 | $827.42 | $3,539.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.52 / $1,558.41 / $2,949.01
| Professional | | $143.52 | $1,558.41 | $2,949.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.07 / $2,112.84 / $4,903.54
| Professional | | $1,265.07 | $2,112.84 | $4,903.54 |