- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $707.95 / $2,454.71
| Professional | | $138.04 | $707.95 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,884.03
| Professional | | $1,096.48 | $1,096.48 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $549.54 / $2,884.03
| Professional | | $190.55 | $549.54 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $2,290.87
| Professional | | $891.25 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $870.96 / $1,819.70
| Professional | | $154.88 | $870.96 | $1,819.70 |