- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $758.58 / $1,659.59
| Professional | | $199.53 | $758.58 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $3,090.30
| Professional | | $1,202.26 | $1,202.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $707.95 / $3,090.30
| Professional | | $234.42 | $707.95 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,479.11 / $2,454.71
| Professional | | $954.99 | $1,479.11 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $954.99 / $1,949.84
| Professional | | $229.09 | $954.99 | $1,949.84 |