- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.93 / $340.99 / $1,831.60
| Professional | | $305.93 | $340.99 | $1,831.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,831.60 / $2,159.05 / $4,753.53
| Professional | | $1,831.60 | $2,159.05 | $4,753.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.70 / $1,360.70 / $3,850.62
| Professional | | $411.70 | $1,360.70 | $3,850.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $412.35 / $1,982.51 / $3,190.93
| Professional | | $412.35 | $1,982.51 | $3,190.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,898.24 / $2,333.69 / $5,834.43
| Professional | | $1,898.24 | $2,333.69 | $5,834.43 |