- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.12 / $1,247.33 / $2,130.02
| Professional | | $187.12 | $1,247.33 | $2,130.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.10 / $822.45 / $2,766.26
| Professional | | $219.10 | $822.45 | $2,766.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.06 / $1,242.39 / $3,139.59
| Professional | | $228.06 | $1,242.39 | $3,139.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.90 / $1,206.26 / $3,875.00
| Professional | | $209.90 | $1,206.26 | $3,875.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.66 / $1,036.40 / $2,039.92
| Professional | | $191.66 | $1,036.40 | $2,039.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,455.67 / $2,110.92 / $3,480.34
| Professional | | $1,455.67 | $2,110.92 | $3,480.34 |