- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.97 / $1,120.60 / $1,705.93
| Professional | | $164.97 | $1,120.60 | $1,705.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.71 / $1,116.66 / $4,015.70
| Professional | | $194.71 | $1,116.66 | $4,015.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.72 / $1,841.08 / $2,117.03
| Professional | | $327.72 | $1,841.08 | $2,117.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.35 / $1,319.17 / $2,221.26
| Professional | | $143.35 | $1,319.17 | $2,221.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.55 / $1,832.41 / $4,488.10
| Professional | | $1,096.55 | $1,832.41 | $4,488.10 |