- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.40 / $902.76 / $2,300.50
| Professional | | $507.40 | $902.76 | $2,300.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.88 / $1,201.13 / $2,507.64
| Professional | | $417.88 | $1,201.13 | $2,507.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $543.33 / $1,377.58 / $2,784.00
| Professional | | $543.33 | $1,377.58 | $2,784.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.03 / $1,184.03 / $2,059.17
| Professional | | $632.03 | $1,184.03 | $2,059.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.41 / $1,408.30 / $1,940.53
| Professional | | $140.41 | $1,408.30 | $1,940.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.77 / $1,198.09 / $2,387.10
| Professional | | $562.77 | $1,198.09 | $2,387.10 |