- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,445.44 / $2,884.03
| Professional | | $371.54 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $389.05 / $1,288.25
| Professional | | $354.81 | $389.05 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,258.93 / $3,311.31
| Professional | | $389.05 | $1,258.93 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $3,311.31
| Professional | | $1,318.26 | $1,737.80 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,348.96 / $3,467.37
| Professional | | $389.05 | $1,348.96 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $2,344.23
| Professional | | $1,412.54 | $1,995.26 | $2,344.23 |