- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.38 / $1,288.52 / $2,200.82
| Professional | | $433.38 | $1,288.52 | $2,200.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $711.00 / $711.00 / $2,319.41
| Professional | | $711.00 | $711.00 | $2,319.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.25 / $1,423.56 / $3,852.78
| Professional | | $422.25 | $1,423.56 | $3,852.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.33 / $3,715.40 / $20,549.21
| Professional | | $1,632.33 | $3,715.40 | $20,549.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,527.50 / $2,444.00 / $4,057.69
| Professional | | $1,527.50 | $2,444.00 | $4,057.69 |