- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,479.11 / $2,398.83
| Professional | | $676.08 | $1,479.11 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $4,168.69
| Professional | | $1,949.84 | $1,949.84 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,698.24 / $3,388.44
| Professional | | $933.25 | $1,698.24 | $3,388.44 |
- 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
- $707.95 / $1,548.82 / $3,090.30
| Professional | | $707.95 | $1,548.82 | $3,090.30 |