- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,288.25 / $2,691.53
| Professional | | $354.81 | $1,288.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $1,737.80 / $4,265.80
| Professional | | $616.60 | $1,737.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,290.87 / $5,888.44
| Professional | | $794.33 | $2,290.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,089.30 / $5,248.07
| Professional | | $794.33 | $2,089.30 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,981.07 / $6,760.83
| Professional | | $2,290.87 | $3,981.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,698.24 / $5,370.32
| Professional | | $660.69 | $1,698.24 | $5,370.32 |