- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.12 / $1,272.33 / $1,519.53
| Professional | | $187.12 | $1,272.33 | $1,519.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.29 / $712.69 / $2,117.48
| Professional | | $174.29 | $712.69 | $2,117.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.44 / $1,038.34 / $2,889.66
| Professional | | $195.44 | $1,038.34 | $2,889.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.38 / $2,695.74 / $8,737.20
| Professional | | $1,458.38 | $2,695.74 | $8,737.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.38 / $2,169.33 / $5,028.51
| Professional | | $1,458.38 | $2,169.33 | $5,028.51 |