- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.87 / $2,039.89 / $3,046.36
| Professional | | $418.87 | $2,039.89 | $3,046.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.19 / $2,459.96 / $6,619.20
| Professional | | $845.19 | $2,459.96 | $6,619.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $617.27 / $1,982.12 / $7,110.06
| Professional | | $617.27 | $1,982.12 | $7,110.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.80 / $2,595.17 / $6,493.61
| Professional | | $806.80 | $2,595.17 | $6,493.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,260.56 / $4,603.10 / $9,678.12
| Professional | | $2,260.56 | $4,603.10 | $9,678.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,224.19 / $4,034.76 / $8,337.08
| Professional | | $2,224.19 | $4,034.76 | $8,337.08 |