- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.65 / $218.72 / $2,727.62
| Professional | | $182.65 | $218.72 | $2,727.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,615.34 / $2,615.34 / $6,202.90
| Professional | | $2,615.34 | $2,615.34 | $6,202.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.90 / $2,771.08 / $6,202.90
| Professional | | $240.90 | $2,771.08 | $6,202.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.90 / $2,771.08 / $6,202.90
| Professional | | $240.90 | $2,771.08 | $6,202.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.28 / $3,079.27 / $7,613.37
| Professional | | $2,591.28 | $3,079.27 | $7,613.37 |