- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.54 / $208.76 / $2,209.14
| Professional | | $166.54 | $208.76 | $2,209.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.85 / $402.62 / $3,748.61
| Professional | | $227.85 | $402.62 | $3,748.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.54 / $446.15 / $4,851.88
| Professional | | $265.54 | $446.15 | $4,851.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.10 / $599.91 / $4,195.29
| Professional | | $260.10 | $599.91 | $4,195.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.54 / $173.77 / $2,209.14
| Professional | | $166.54 | $173.77 | $2,209.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.73 / $3,071.01 / $4,647.77
| Professional | | $2,170.73 | $3,071.01 | $4,647.77 |