- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,784.38 / $2,812.22
| Professional | | $2,784.38 | $2,784.38 | $2,812.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.81 / $112.71 / $2,784.38
| Professional | | $95.81 | $112.71 | $2,784.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.24 / $143.60 / $161.83
| Professional | | $129.24 | $143.60 | $161.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,062.82 / $3,341.25 / $3,898.13
| Professional | | $3,062.82 | $3,341.25 | $3,898.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.81 / $2,784.38 / $4,176.57
| Professional | | $95.81 | $2,784.38 | $4,176.57 |