- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,691.53 / $5,888.44
| Professional | | $181.97 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $218.78 / $281.84
| Professional | | $199.53 | $218.78 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $3,235.94 / $7,762.47
| Professional | | $208.93 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,897.79 / $8,511.38
| Professional | | $3,715.35 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $2,754.23 / $7,079.46
| Professional | | $194.98 | $2,754.23 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,623.41 / $6,309.57
| Professional | | $3,388.44 | $5,623.41 | $6,309.57 |