- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.72 / $1,030.90 / $1,283.70
| Professional | | $873.72 | $1,030.90 | $1,283.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.22 / $796.08 / $936.57
| Professional | | $100.22 | $796.08 | $936.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.41 / $3,044.55 / $3,188.01
| Professional | | $289.41 | $3,044.55 | $3,188.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $670.00 / $670.00 / $670.00
| Professional | | $670.00 | $670.00 | $670.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.16 / $274.31 / $714.98
| Professional | | $65.16 | $274.31 | $714.98 |