- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $741.31 / $6,165.95
| Professional | | $169.82 | $741.31 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $426.58 / $5,370.32
| Professional | | $223.87 | $426.58 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.15 / $4,570.88 / $6,760.83
| Professional | | $269.15 | $4,570.88 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $4,786.30 / $7,585.78
| Professional | | $239.88 | $4,786.30 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $741.31 / $10,000.00
| Professional | | $165.96 | $741.31 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $3,715.35 / $7,585.78
| Professional | | $257.04 | $3,715.35 | $7,585.78 |