- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.74 / $685.77 / $1,183.65
| Professional | | $229.74 | $685.77 | $1,183.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.76 / $1,000.49 / $2,703.14
| Professional | | $848.76 | $1,000.49 | $2,703.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.54 / $758.79 / $2,703.14
| Professional | | $318.54 | $758.79 | $2,703.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.93 / $1,024.36 / $2,703.14
| Professional | | $356.93 | $1,024.36 | $2,703.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.24 / $1,050.01 / $3,317.81
| Professional | | $842.24 | $1,050.01 | $3,317.81 |