- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.90 / $196.32 / $1,156.80
| Professional | | $167.90 | $196.32 | $1,156.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.23 / $1,332.23 / $2,976.21
| Professional | | $1,332.23 | $1,332.23 | $2,976.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.52 / $1,162.09 / $2,976.21
| Professional | | $217.52 | $1,162.09 | $2,976.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.52 / $1,162.09 / $2,976.21
| Professional | | $217.52 | $1,162.09 | $2,976.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.81 / $1,271.24 / $3,652.97
| Professional | | $845.81 | $1,271.24 | $3,652.97 |