- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.82 / $1,321.55 / $2,306.03
| Professional | | $331.82 | $1,321.55 | $2,306.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.66 / $1,477.56 / $4,426.70
| Professional | | $663.66 | $1,477.56 | $4,426.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.98 / $1,403.45 / $2,271.81
| Professional | | $775.98 | $1,403.45 | $2,271.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.00 / $1,623.78 / $5,591.87
| Professional | | $450.00 | $1,623.78 | $5,591.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.57 / $2,238.21 / $4,139.95
| Professional | | $1,424.57 | $2,238.21 | $4,139.95 |