- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.28 / $1,710.50 / $2,654.38
| Professional | | $390.28 | $1,710.50 | $2,654.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.46 / $1,037.53 / $3,728.13
| Professional | | $430.46 | $1,037.53 | $3,728.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.27 / $1,843.74 / $2,600.10
| Professional | | $1,218.27 | $1,843.74 | $2,600.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.63 / $1,936.33 / $3,152.36
| Professional | | $1,226.63 | $1,936.33 | $3,152.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,759.02 / $2,552.91 / $4,529.92
| Professional | | $1,759.02 | $2,552.91 | $4,529.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.01 / $1,423.94 / $1,423.94
| Professional | | $312.01 | $1,423.94 | $1,423.94 |