- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $2,951.21 / $5,888.44
| Professional | | $181.97 | $2,951.21 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $2,951.21 / $10,471.29
| Professional | | $218.78 | $2,951.21 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $4,897.79 / $7,585.78
| Professional | | $363.08 | $4,897.79 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $3,715.35 / $7,762.47
| Professional | | $169.82 | $3,715.35 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,949.84 / $7,079.46
| Professional | | $125.89 | $1,949.84 | $7,079.46 |