- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.67 / $339.21 / $885.30
| Professional | | $60.67 | $339.21 | $885.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.60 / $839.60 / $2,236.64
| Professional | | $839.60 | $839.60 | $2,236.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.71 / $317.17 / $2,236.64
| Professional | | $93.71 | $317.17 | $2,236.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.09 / $934.38 / $2,236.64
| Professional | | $101.09 | $934.38 | $2,236.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.25 / $1,042.09 / $2,745.23
| Professional | | $782.25 | $1,042.09 | $2,745.23 |