- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.41 / $1,810.86 / $3,784.71
| Professional | | $612.41 | $1,810.86 | $3,784.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $544.57 / $1,428.05 / $5,083.03
| Professional | | $544.57 | $1,428.05 | $5,083.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $662.83 / $1,978.52 / $6,270.21
| Professional | | $662.83 | $1,978.52 | $6,270.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,282.42 / $2,282.42 / $3,335.82
| Professional | | $2,282.42 | $2,282.42 | $3,335.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.97 / $2,922.85 / $6,487.90
| Professional | | $1,675.97 | $2,922.85 | $6,487.90 |