- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.03 / $253.23 / $1,096.85
| Professional | | $156.03 | $253.23 | $1,096.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.29 / $2,500.29 / $2,500.29
| Professional | | $2,500.29 | $2,500.29 | $2,500.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.21 / $552.38 / $2,500.29
| Professional | | $148.21 | $552.38 | $2,500.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.90 / $829.91 / $2,500.29
| Professional | | $166.90 | $829.91 | $2,500.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $708.43 / $901.64 / $3,068.82
| Professional | | $708.43 | $901.64 | $3,068.82 |