- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.68 / $1,120.60 / $1,405.45
| Professional | | $193.68 | $1,120.60 | $1,405.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.94 / $757.35 / $1,738.69
| Professional | | $141.94 | $757.35 | $1,738.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.26 / $1,817.66 / $1,817.66
| Professional | | $1,416.26 | $1,817.66 | $1,817.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.00 / $1,116.66 / $2,267.21
| Professional | | $202.00 | $1,116.66 | $2,267.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.87 / $1,772.06 / $2,816.80
| Professional | | $1,326.87 | $1,772.06 | $2,816.80 |