- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.93 / $1,246.21 / $2,573.05
| Professional | | $362.93 | $1,246.21 | $2,573.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.06 / $756.20 / $1,237.41
| Professional | | $318.06 | $756.20 | $1,237.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $429.16 / $1,239.44 / $3,616.61
| Professional | | $429.16 | $1,239.44 | $3,616.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.00 / $2,647.68 / $20,549.21
| Professional | | $1,548.00 | $2,647.68 | $20,549.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.00 / $2,150.01 / $3,370.27
| Professional | | $1,462.00 | $2,150.01 | $3,370.27 |