- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.95 / $2,059.63 / $10,718.30
| Professional | | $597.95 | $2,059.63 | $10,718.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.99 / $1,317.60 / $4,354.47
| Professional | | $356.99 | $1,317.60 | $4,354.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,474.75 / $2,474.75 / $2,474.75
| Professional | | $2,474.75 | $2,474.75 | $2,474.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.60 / $4,187.46 / $6,273.89
| Professional | | $3,265.60 | $4,187.46 | $6,273.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,818.25 / $5,788.08 / $10,866.52
| Professional | | $3,818.25 | $5,788.08 | $10,866.52 |