- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.45 / $633.61 / $2,058.48
| Professional | | $114.45 | $633.61 | $2,058.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,334.69 / $1,334.69 / $4,740.85
| Professional | | $1,334.69 | $1,334.69 | $4,740.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.56 / $1,036.97 / $4,740.85
| Professional | | $171.56 | $1,036.97 | $4,740.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.25 / $1,420.93 / $4,740.85
| Professional | | $194.25 | $1,420.93 | $4,740.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,393.46 / $1,696.38 / $5,818.86
| Professional | | $1,393.46 | $1,696.38 | $5,818.86 |