- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.72 / $1,508.19 / $1,554.96
| Professional | | $221.72 | $1,508.19 | $1,554.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.66 / $237.90 / $1,765.72
| Professional | | $216.66 | $237.90 | $1,765.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.10 / $1,145.58 / $2,088.81
| Professional | | $190.10 | $1,145.58 | $2,088.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,239.61 / $1,822.98 / $8,737.20
| Professional | | $1,239.61 | $1,822.98 | $8,737.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.70 / $1,641.22 / $2,320.94
| Professional | | $1,166.70 | $1,641.22 | $2,320.94 |