- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,691.53 / $5,495.41
| Professional | | $707.95 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,388.44 / $3,388.44
| Professional | | $2,818.38 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $3,548.13 / $7,244.36
| Professional | | $954.99 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,511.89 / $6,606.93
| Professional | | $741.31 | $2,511.89 | $6,606.93 |