- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.43 / $2,123.52 / $3,199.83
| Professional | | $436.43 | $2,123.52 | $3,199.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.04 / $1,019.29 / $4,093.16
| Professional | | $524.04 | $1,019.29 | $4,093.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.58 / $1,556.36 / $2,048.62
| Professional | | $1,252.58 | $1,556.36 | $2,048.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.08 / $1,221.86 / $4,493.18
| Professional | | $580.08 | $1,221.86 | $4,493.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,033.79 / $2,763.64 / $4,572.67
| Professional | | $2,033.79 | $2,763.64 | $4,572.67 |