- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $1,737.80
| Professional | | $870.96 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $389.05 / $2,344.23
| Professional | | $123.03 | $389.05 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $1,230.27 / $1,905.46
| Professional | | $363.08 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $1,548.82 / $4,168.69
| Professional | | $380.19 | $1,548.82 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,288.25 / $1,380.38
| Professional | | $1,230.27 | $1,288.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,202.26 / $1,905.46
| Professional | | $676.08 | $1,202.26 | $1,905.46 |