- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.89 / $307.39 / $1,736.61
| Professional | | $116.89 | $307.39 | $1,736.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.64 / $427.67 / $2,266.19
| Professional | | $186.64 | $427.67 | $2,266.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.43 / $738.53 / $4,023.35
| Professional | | $365.43 | $738.53 | $4,023.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.52 / $1,255.32 / $3,874.55
| Professional | | $282.52 | $1,255.32 | $3,874.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,966.84 / $2,521.39 / $5,461.69
| Professional | | $1,966.84 | $2,521.39 | $5,461.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.34 / $1,112.01 / $1,623.52
| Professional | | $143.34 | $1,112.01 | $1,623.52 |