- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.48 / $1,299.58 / $2,306.03
| Professional | | $346.48 | $1,299.58 | $2,306.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.35 / $1,530.47 / $3,378.36
| Professional | | $409.35 | $1,530.47 | $3,378.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.36 / $1,248.16 / $3,763.19
| Professional | | $391.36 | $1,248.16 | $3,763.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,836.34 / $3,418.62 / $21,581.96
| Professional | | $1,836.34 | $3,418.62 | $21,581.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,600.21 / $2,809.44 / $4,634.49
| Professional | | $1,600.21 | $2,809.44 | $4,634.49 |