- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $445.34 / $1,336.78 / $3,067.92
| Professional | | $445.34 | $1,336.78 | $3,067.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $460.74 / $1,745.39 / $6,071.26
| Professional | | $460.74 | $1,745.39 | $6,071.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.37 / $2,065.88 / $2,540.06
| Professional | | $664.37 | $2,065.88 | $2,540.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.01 / $1,443.32 / $2,805.75
| Professional | | $289.01 | $1,443.32 | $2,805.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.49 / $2,934.21 / $3,956.55
| Professional | | $1,441.49 | $2,934.21 | $3,956.55 |