- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.06 / $709.37 / $2,343.98
| Professional | | $86.06 | $709.37 | $2,343.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.16 / $376.00 / $2,575.58
| Professional | | $131.16 | $376.00 | $2,575.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.60 / $235.72 / $2,272.61
| Professional | | $161.60 | $235.72 | $2,272.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.76 / $1,226.88 / $2,175.30
| Professional | | $140.76 | $1,226.88 | $2,175.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.91 / $1,200.32 / $2,520.39
| Professional | | $161.91 | $1,200.32 | $2,520.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.79 / $1,596.85 / $2,635.69
| Professional | | $163.79 | $1,596.85 | $2,635.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.76 / $1,858.45 / $3,007.03
| Professional | | $1,178.76 | $1,858.45 | $3,007.03 |