- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,288.25 / $2,511.89
| Professional | | $354.81 | $1,288.25 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $436.52 / $537.03
| Professional | | $107.15 | $436.52 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,148.15 / $2,754.23
| Professional | | $363.08 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,737.80 / $2,951.21
| Professional | | $407.38 | $1,737.80 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,148.15 / $2,691.53
| Professional | | $398.11 | $1,148.15 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $1,445.44 / $3,467.37
| Professional | | $467.74 | $1,445.44 | $3,467.37 |