- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $512.86 / $1,778.28
| Professional | | $83.18 | $512.86 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $346.74 / $2,398.83
| Professional | | $109.65 | $346.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $223.87 / $2,454.71
| Professional | | $151.36 | $223.87 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $1,202.26 / $2,137.96
| Professional | | $144.54 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $234.42 / $2,398.83
| Professional | | $79.43 | $234.42 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $1,445.44 / $2,398.83
| Professional | | $162.18 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $741.31 / $2,398.83
| Professional | | $128.82 | $741.31 | $2,398.83 |