- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,691.53 / $5,888.44
| Professional | | $707.95 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,187.76 / $9,549.93
| Professional | | $1,513.56 | $2,187.76 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,630.27 / $10,964.78
| Professional | | $933.25 | $2,630.27 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $7,585.78 / $29,512.09
| Professional | | $3,801.89 | $7,585.78 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,344.23 / $8,912.51
| Professional | | $977.24 | $2,344.23 | $8,912.51 |