- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $341.41 / $1,437.40 / $2,677.30
| Professional | | $341.41 | $1,437.40 | $2,677.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.10 / $2,014.68 / $4,799.70
| Professional | | $661.10 | $2,014.68 | $4,799.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.37 / $2,452.42 / $5,926.16
| Professional | | $857.37 | $2,452.42 | $5,926.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $762.42 / $2,333.00 / $5,148.75
| Professional | | $762.42 | $2,333.00 | $5,148.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,720.36 / $4,441.00 / $6,750.58
| Professional | | $2,720.36 | $4,441.00 | $6,750.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,895.49 / $4,021.94 / $6,440.41
| Professional | | $1,895.49 | $4,021.94 | $6,440.41 |