- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.81 / $381.15 / $1,882.26
| Professional | | $320.81 | $381.15 | $1,882.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.97 / $1,806.97 / $5,016.81
| Professional | | $1,806.97 | $1,806.97 | $5,016.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.40 / $2,049.98 / $5,016.81
| Professional | | $418.40 | $2,049.98 | $5,016.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.40 / $2,049.98 / $5,016.81
| Professional | | $418.40 | $2,049.98 | $5,016.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.83 / $2,166.33 / $6,157.58
| Professional | | $2,051.83 | $2,166.33 | $6,157.58 |