- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.28 / $1,546.89 / $2,846.21
| Professional | | $756.28 | $1,546.89 | $2,846.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.65 / $1,616.61 / $3,143.67
| Professional | | $853.65 | $1,616.61 | $3,143.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $269.97 / $2,249.75
| Professional | | $32.34 | $269.97 | $2,249.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $947.75 / $1,838.50 / $3,268.21
| Professional | | $947.75 | $1,838.50 | $3,268.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.93 / $2,484.73 / $3,849.30
| Professional | | $1,753.93 | $2,484.73 | $3,849.30 |