- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.89 / $1,107.35 / $2,471.44
| Professional | | $116.89 | $1,107.35 | $2,471.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.45 / $1,952.38 / $5,099.20
| Professional | | $186.45 | $1,952.38 | $5,099.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.61 / $908.43 / $4,424.01
| Professional | | $305.61 | $908.43 | $4,424.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,420.30 / $1,674.48 / $2,987.52
| Professional | | $1,420.30 | $1,674.48 | $2,987.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.91 / $1,388.54 / $3,458.30
| Professional | | $217.91 | $1,388.54 | $3,458.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.51 / $3,170.90 / $8,185.83
| Professional | | $1,877.51 | $3,170.90 | $8,185.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.29 / $2,473.87 / $4,284.26
| Professional | | $1,712.29 | $2,473.87 | $4,284.26 |