- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.61 / $209.61 / $4,046.70
| Professional | | $209.61 | $209.61 | $4,046.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.19 / $226.93 / $7,706.00
| Professional | | $208.19 | $226.93 | $7,706.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.05 / $3,530.58 / $11,125.20
| Professional | | $218.05 | $3,530.58 | $11,125.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.89 / $8,655.95 / $8,655.95
| Professional | | $471.89 | $8,655.95 | $8,655.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,837.86 / $7,642.28 / $10,002.65
| Professional | | $3,837.86 | $7,642.28 | $10,002.65 |