- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.81 / $1,117.89 / $1,876.87
| Professional | | $65.81 | $1,117.89 | $1,876.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,533.26 / $1,807.38 / $4,916.93
| Professional | | $1,533.26 | $1,807.38 | $4,916.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.34 / $937.40 / $2,405.96
| Professional | | $67.34 | $937.40 | $2,405.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.70 / $1,635.27 / $2,405.96
| Professional | | $76.70 | $1,635.27 | $2,405.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,364.55 / $1,943.59 / $5,888.33
| Professional | | $1,364.55 | $1,943.59 | $5,888.33 |