- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.63 / $1,064.93 / $2,230.52
| Professional | | $182.63 | $1,064.93 | $2,230.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.37 / $1,095.92 / $2,612.84
| Professional | | $184.37 | $1,095.92 | $2,612.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.86 / $853.14 / $2,681.61
| Professional | | $218.86 | $853.14 | $2,681.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,245.31 / $8,185.83 / $9,587.93
| Professional | | $4,245.31 | $8,185.83 | $9,587.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,361.34 / $2,077.14 / $3,200.87
| Professional | | $1,361.34 | $2,077.14 | $3,200.87 |