- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.58 / $1,319.49 / $1,857.49
| Professional | | $327.58 | $1,319.49 | $1,857.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.02 / $795.52 / $2,651.55
| Professional | | $350.02 | $795.52 | $2,651.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.32 / $2,612.08 / $4,540.47
| Professional | | $797.32 | $2,612.08 | $4,540.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.64 / $3,577.09 / $21,581.96
| Professional | | $1,968.64 | $3,577.09 | $21,581.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.25 / $3,063.19 / $4,545.70
| Professional | | $817.25 | $3,063.19 | $4,545.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $3,902.50 / $4,731.80
| Professional | | $5.00 | $3,902.50 | $4,731.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.08 / $3,408.24 / $4,441.00
| Professional | | $2,320.08 | $3,408.24 | $4,441.00 |