- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,548.82 / $2,344.23
| Professional | | $724.44 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $6,918.31 / $15,135.61
| Professional | | $724.44 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,698.24 / $4,466.84
| Professional | | $758.58 | $1,698.24 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $3,801.89
| Professional | | $1,659.59 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,659.59 / $4,168.69
| Professional | | $707.95 | $1,659.59 | $4,168.69 |