- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.03 / $1,490.25 / $2,677.30
| Professional | | $374.03 | $1,490.25 | $2,677.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.62 / $1,268.79 / $3,583.20
| Professional | | $519.62 | $1,268.79 | $3,583.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $1,148.51 / $1,987.17
| Professional | | $32.34 | $1,148.51 | $1,987.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.62 / $1,652.62 / $3,517.19
| Professional | | $519.62 | $1,652.62 | $3,517.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,216.98 / $3,323.83 / $4,879.83
| Professional | | $2,216.98 | $3,323.83 | $4,879.83 |