- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.43 / $516.97 / $1,214.13
| Professional | | $204.43 | $516.97 | $1,214.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.58 / $1,203.58 / $3,101.09
| Professional | | $1,203.58 | $1,203.58 | $3,101.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.92 / $712.34 / $3,101.09
| Professional | | $287.92 | $712.34 | $3,101.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.52 / $1,365.86 / $3,101.09
| Professional | | $309.52 | $1,365.86 | $3,101.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,236.30 / $1,498.08 / $3,806.24
| Professional | | $1,236.30 | $1,498.08 | $3,806.24 |