- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.40 / $1,410.93 / $2,677.30
| Professional | | $344.40 | $1,410.93 | $2,677.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.48 / $976.37 / $2,967.00
| Professional | | $332.48 | $976.37 | $2,967.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.96 / $1,427.03 / $3,562.63
| Professional | | $516.96 | $1,427.03 | $3,562.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,263.56 / $1,891.02 / $2,047.27
| Professional | | $1,263.56 | $1,891.02 | $2,047.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.33 / $1,246.22 / $2,055.12
| Professional | | $103.33 | $1,246.22 | $2,055.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.25 / $2,560.69 / $5,208.63
| Professional | | $1,463.25 | $2,560.69 | $5,208.63 |