- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.97 / $1,335.96 / $2,128.13
| Professional | | $164.97 | $1,335.96 | $2,128.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.87 / $1,331.38 / $1,925.65
| Professional | | $219.87 | $1,331.38 | $1,925.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.45 / $1,268.98 / $2,334.75
| Professional | | $203.45 | $1,268.98 | $2,334.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,649.79
| Professional | | $32.34 | $32.34 | $1,649.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.60 / $1,434.69 / $2,334.75
| Professional | | $217.60 | $1,434.69 | $2,334.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,866.48 / $2,290.69 / $3,273.20
| Professional | | $1,866.48 | $2,290.69 | $3,273.20 |