- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.92 / $948.67 / $4,544.18
| Professional | | $87.92 | $948.67 | $4,544.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.54 / $590.65 / $2,788.31
| Professional | | $105.54 | $590.65 | $2,788.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.17 / $875.81 / $5,549.17
| Professional | | $234.17 | $875.81 | $5,549.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.75 / $1,684.20 / $5,378.10
| Professional | | $308.75 | $1,684.20 | $5,378.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.44 / $987.07 / $5,242.90
| Professional | | $189.44 | $987.07 | $5,242.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,899.61 / $2,489.08 / $6,152.86
| Professional | | $1,899.61 | $2,489.08 | $6,152.86 |