- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.80 / $376.30 / $1,798.56
| Professional | | $318.80 | $376.30 | $1,798.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.35 / $2,122.21 / $4,462.02
| Professional | | $1,800.35 | $2,122.21 | $4,462.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.20 / $1,272.72 / $3,757.07
| Professional | | $432.20 | $1,272.72 | $3,757.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.04 / $1,827.57 / $2,839.50
| Professional | | $459.04 | $1,827.57 | $2,839.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.18 / $2,292.96 / $5,476.64
| Professional | | $1,689.18 | $2,292.96 | $5,476.64 |