- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.56 / $85.56 / $762.46
| Professional | | $85.56 | $85.56 | $762.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.91 / $97.37 / $6,000.00
| Professional | | $92.91 | $97.37 | $6,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.33 / $648.48 / $2,008.88
| Professional | | $84.33 | $648.48 | $2,008.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.35 / $1,549.41 / $1,549.41
| Professional | | $674.35 | $1,549.41 | $1,549.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.63 / $1,084.98 / $1,795.24
| Professional | | $664.63 | $1,084.98 | $1,795.24 |