- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.84 / $1,523.13 / $2,113.50
| Professional | | $719.84 | $1,523.13 | $2,113.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.20 / $1,924.25 / $4,482.10
| Professional | | $814.20 | $1,924.25 | $4,482.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.06 / $2,065.12 / $2,604.19
| Professional | | $1,518.06 | $2,065.12 | $2,604.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.51 / $1,720.39 / $3,654.91
| Professional | | $696.51 | $1,720.39 | $3,654.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.14 / $2,125.19 / $5,595.82
| Professional | | $1,242.14 | $2,125.19 | $5,595.82 |