- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.39 / $1,395.46 / $1,874.08
| Professional | | $183.39 | $1,395.46 | $1,874.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.61 / $1,266.16 / $3,980.63
| Professional | | $319.61 | $1,266.16 | $3,980.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.64 / $1,146.30 / $4,911.85
| Professional | | $381.64 | $1,146.30 | $4,911.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $352.84 / $1,134.95 / $3,978.68
| Professional | | $352.84 | $1,134.95 | $3,978.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,990.53 / $3,442.67 / $6,140.36
| Professional | | $1,990.53 | $3,442.67 | $6,140.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.60 / $3,121.14 / $5,863.05
| Professional | | $1,601.60 | $3,121.14 | $5,863.05 |