- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.81 / $1,738.27 / $3,463.54
| Professional | | $417.81 | $1,738.27 | $3,463.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.57 / $1,769.78 / $4,111.43
| Professional | | $516.57 | $1,769.78 | $4,111.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $447.74 / $1,046.99 / $4,048.82
| Professional | | $447.74 | $1,046.99 | $4,048.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,036.51 / $13,270.96 / $15,786.53
| Professional | | $7,036.51 | $13,270.96 | $15,786.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,002.35 / $2,955.11 / $4,655.46
| Professional | | $2,002.35 | $2,955.11 | $4,655.46 |