- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.00 / $1,319.49 / $2,252.29
| Professional | | $404.00 | $1,319.49 | $2,252.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.00 / $712.00 / $2,485.32
| Professional | | $712.00 | $712.00 | $2,485.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.50 / $1,469.01 / $4,176.97
| Professional | | $392.50 | $1,469.01 | $4,176.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,682.02 / $3,877.55 / $21,581.96
| Professional | | $1,682.02 | $3,877.55 | $21,581.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.69 / $2,518.40 / $3,906.86
| Professional | | $1,567.69 | $2,518.40 | $3,906.86 |