- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.68 / $1,374.93 / $3,769.88
| Professional | | $197.68 | $1,374.93 | $3,769.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.00 / $1,217.79 / $2,103.94
| Professional | | $199.00 | $1,217.79 | $2,103.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.07 / $1,219.22 / $1,983.07
| Professional | | $159.07 | $1,219.22 | $1,983.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.74 / $1,032.58 / $1,851.06
| Professional | | $138.74 | $1,032.58 | $1,851.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.16 / $231.24 / $1,630.41
| Professional | | $154.16 | $231.24 | $1,630.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,454.76 / $1,929.26 / $2,678.11
| Professional | | $1,454.76 | $1,929.26 | $2,678.11 |