- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,691.53 / $5,370.32
| Professional | | $724.44 | $2,691.53 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $1,174.90 / $1,737.80
| Professional | | $234.42 | $1,174.90 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,290.87 / $6,165.95
| Professional | | $741.31 | $2,290.87 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $4,073.80 / $5,754.40
| Professional | | $776.25 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $1,348.96 / $6,025.60
| Professional | | $602.56 | $1,348.96 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,187.76 / $5,248.07
| Professional | | $851.14 | $2,187.76 | $5,248.07 |