- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.34 / $369.82 / $3,070.55
| Professional | | $162.34 | $369.82 | $3,070.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.77 / $424.40 / $2,960.43
| Professional | | $243.77 | $424.40 | $2,960.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.93 / $424.77 / $3,462.37
| Professional | | $250.93 | $424.77 | $3,462.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.00 / $428.73 / $2,891.37
| Professional | | $217.00 | $428.73 | $2,891.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.62 / $356.12 / $3,070.55
| Professional | | $169.62 | $356.12 | $3,070.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,986.11 / $2,792.63 / $3,442.43
| Professional | | $1,986.11 | $2,792.63 | $3,442.43 |