- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.84 / $303.79 / $1,450.66
| Professional | | $223.84 | $303.79 | $1,450.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,293.44 / $1,524.68 / $3,821.15
| Professional | | $1,293.44 | $1,524.68 | $3,821.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.87 / $617.69 / $2,738.65
| Professional | | $348.87 | $617.69 | $2,738.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.87 / $475.88 / $2,704.92
| Professional | | $348.87 | $475.88 | $2,704.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,108.67 / $1,673.51 / $4,690.04
| Professional | | $1,108.67 | $1,673.51 | $4,690.04 |