- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.32 / $1,111.83 / $1,637.29
| Professional | | $384.32 | $1,111.83 | $1,637.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.17 / $432.92 / $7,706.00
| Professional | | $397.17 | $432.92 | $7,706.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $471.40 / $1,419.58 / $5,414.37
| Professional | | $471.40 | $1,419.58 | $5,414.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.41 / $3,351.43 / $3,351.43
| Professional | | $1,470.41 | $3,351.43 | $3,351.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.73 / $2,833.98 / $4,647.38
| Professional | | $1,394.73 | $2,833.98 | $4,647.38 |