- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.65 / $1,022.77 / $1,692.97
| Professional | | $214.65 | $1,022.77 | $1,692.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.66 / $1,491.66 / $3,666.03
| Professional | | $1,491.66 | $1,491.66 | $3,666.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.00 / $845.47 / $3,666.03
| Professional | | $288.00 | $845.47 | $3,666.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.56 / $1,651.36 / $3,666.03
| Professional | | $322.56 | $1,651.36 | $3,666.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,699.09 / $2,231.21 / $4,499.64
| Professional | | $1,699.09 | $2,231.21 | $4,499.64 |