- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.33 / $1,224.94 / $1,652.34
| Professional | | $201.33 | $1,224.94 | $1,652.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.30 / $204.30 / $247.20
| Professional | | $204.30 | $204.30 | $247.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.30 / $1,100.28 / $2,586.63
| Professional | | $180.30 | $1,100.28 | $2,586.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.62 / $1,523.26 / $2,841.37
| Professional | | $885.62 | $1,523.26 | $2,841.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,306.19 / $1,742.52 / $2,697.59
| Professional | | $1,306.19 | $1,742.52 | $2,697.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.82 / $1,180.82 / $1,668.98
| Professional | | $1,180.82 | $1,180.82 | $1,668.98 |