- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.96 / $3,519.48 / $6,698.85
| Professional | | $779.96 | $3,519.48 | $6,698.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.80 / $1,792.97 / $3,507.98
| Professional | | $804.80 | $1,792.97 | $3,507.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.93 / $2,394.13 / $9,390.02
| Professional | | $1,226.93 | $2,394.13 | $9,390.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,374.28 / $4,752.93 / $7,029.93
| Professional | | $3,374.28 | $4,752.93 | $7,029.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,222.55 / $6,650.98 / $11,871.45
| Professional | | $3,222.55 | $6,650.98 | $11,871.45 |