- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,691.53 / $4,570.88
| Professional | | $181.97 | $2,691.53 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $6,456.54
| Professional | | $1,122.02 | $1,122.02 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $512.86 / $7,079.46
| Professional | | $218.78 | $512.86 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,754.40 / $26,915.35
| Professional | | $3,890.45 | $5,754.40 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $3,311.31 / $5,754.40
| Professional | | $218.78 | $3,311.31 | $5,754.40 |