- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.58 / $1,107.35 / $1,874.08
| Professional | | $187.58 | $1,107.35 | $1,874.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.29 / $805.10 / $2,720.91
| Professional | | $226.29 | $805.10 | $2,720.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.64 / $903.82 / $2,317.38
| Professional | | $226.64 | $903.82 | $2,317.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.64 / $1,531.17 / $3,521.00
| Professional | | $252.64 | $1,531.17 | $3,521.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.73 / $230.97 / $1,485.65
| Professional | | $201.73 | $230.97 | $1,485.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,679.93
| Professional | | $32.34 | $32.34 | $1,679.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,414.25 / $2,084.38 / $3,508.86
| Professional | | $1,414.25 | $2,084.38 | $3,508.86 |