- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $695.40 / $1,561.28 / $4,029.12
| Professional | | $695.40 | $1,561.28 | $4,029.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.46 / $1,897.23 / $2,845.85
| Professional | | $908.46 | $1,897.23 | $2,845.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.82 / $955.73 / $1,472.34
| Professional | | $149.82 | $955.73 | $1,472.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.25 / $2,130.50 / $4,621.53
| Professional | | $961.25 | $2,130.50 | $4,621.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,466.78 / $1,802.65 / $2,874.49
| Professional | | $1,466.78 | $1,802.65 | $2,874.49 |