- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.23 / $1,459.55 / $2,260.75
| Professional | | $674.23 | $1,459.55 | $2,260.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.28 / $1,721.81 / $3,166.79
| Professional | | $867.28 | $1,721.81 | $3,166.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.12 / $1,691.84 / $3,098.38
| Professional | | $886.12 | $1,691.84 | $3,098.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,071.84 / $11,690.80 / $13,588.28
| Professional | | $6,071.84 | $11,690.80 | $13,588.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.17 / $1,865.53 / $3,649.49
| Professional | | $1,433.17 | $1,865.53 | $3,649.49 |