- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.58 / $221.68 / $2,495.31
| Professional | | $186.58 | $221.68 | $2,495.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,395.50 / $2,395.50 / $7,108.38
| Professional | | $2,395.50 | $2,395.50 | $7,108.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.29 / $2,714.56 / $7,108.38
| Professional | | $243.29 | $2,714.56 | $7,108.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.29 / $2,714.56 / $7,108.38
| Professional | | $243.29 | $2,714.56 | $7,108.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,727.05 / $3,227.24 / $8,370.16
| Professional | | $2,727.05 | $3,227.24 | $8,370.16 |