- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $1,096.48 / $2,754.23
| Professional | | $165.96 | $1,096.48 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,148.15 / $3,467.37
| Professional | | $275.42 | $1,148.15 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $446.68 / $2,951.21
| Professional | | $288.40 | $446.68 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $1,412.54 / $3,311.31
| Professional | | $275.42 | $1,412.54 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $489.78 / $3,311.31
| Professional | | $79.43 | $489.78 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $602.56 / $3,090.30
| Professional | | $338.84 | $602.56 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $1,548.82 / $3,630.78
| Professional | | $281.84 | $1,548.82 | $3,630.78 |