- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.84 / $1,818.36 / $8,673.06
| Professional | | $398.84 | $1,818.36 | $8,673.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.00 / $1,011.00 / $1,011.00
| Professional | | $1,011.00 | $1,011.00 | $1,011.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.01 / $1,022.54 / $4,133.68
| Professional | | $509.01 | $1,022.54 | $4,133.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $335.51
| Professional | | $32.34 | $32.34 | $335.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.87 / $2,548.36 / $5,330.63
| Professional | | $1,925.87 | $2,548.36 | $5,330.63 |