- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.36 / $1,459.10 / $3,317.74
| Professional | | $689.36 | $1,459.10 | $3,317.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.59 / $1,318.49 / $2,157.53
| Professional | | $885.59 | $1,318.49 | $2,157.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.30 / $1,499.72 / $2,958.73
| Professional | | $743.30 | $1,499.72 | $2,958.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.45 / $2,004.45 / $12,126.80
| Professional | | $1,469.45 | $2,004.45 | $12,126.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,411.41 / $1,797.18 / $3,308.36
| Professional | | $1,411.41 | $1,797.18 | $3,308.36 |