- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.07 / $1,071.52 / $2,344.23
| Professional | | $66.07 | $1,071.52 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $4,897.79
| Professional | | $1,548.82 | $1,819.70 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $933.25 / $2,398.83
| Professional | | $75.86 | $933.25 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $4,897.79
| Professional | | $1,862.09 | $1,862.09 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.13 / $1,445.44 / $3,548.13
| Professional | | $74.13 | $1,445.44 | $3,548.13 |