- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.28 / $732.46 / $1,055.82
| Professional | | $130.28 | $732.46 | $1,055.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,084.81 / $1,084.81 / $2,896.87
| Professional | | $1,084.81 | $1,084.81 | $2,896.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.00 / $629.47 / $2,896.87
| Professional | | $192.00 | $629.47 | $2,896.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.49 / $1,258.70 / $2,896.87
| Professional | | $196.49 | $1,258.70 | $2,896.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.79 / $1,287.59 / $3,555.59
| Professional | | $1,154.79 | $1,287.59 | $3,555.59 |