- 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
- $710.78 / $2,005.82 / $3,457.78
| Professional | | $710.78 | $2,005.82 | $3,457.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.23 / $1,728.90 / $4,345.03
| Professional | | $627.23 | $1,728.90 | $4,345.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,517.11 / $3,577.09 / $4,195.18
| Professional | | $2,517.11 | $3,577.09 | $4,195.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,204.39 / $3,398.31 / $4,195.18
| Professional | | $2,204.39 | $3,398.31 | $4,195.18 |