- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.34 / $1,274.76 / $2,677.30
| Professional | | $339.34 | $1,274.76 | $2,677.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.45 / $773.76 / $1,266.15
| Professional | | $297.45 | $773.76 | $1,266.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.55 / $1,258.41 / $3,775.62
| Professional | | $399.55 | $1,258.41 | $3,775.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,596.24 / $2,839.90 / $21,581.96
| Professional | | $1,596.24 | $2,839.90 | $21,581.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,463.22 / $2,217.01 / $3,504.46
| Professional | | $1,463.22 | $2,217.01 | $3,504.46 |