- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $660.69 / $2,187.76
| Professional | | $426.58 | $660.69 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $389.05 / $1,819.70
| Professional | | $389.05 | $389.05 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $2,511.89
| Professional | | $891.25 | $1,548.82 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $2,884.03
| Professional | | $1,479.11 | $2,187.76 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $426.58 / $1,288.25
| Professional | | $60.26 | $426.58 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,122.02 / $3,630.78
| Professional | | $501.19 | $1,122.02 | $3,630.78 |