- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.77 / $1,578.41 / $1,605.39
| Professional | | $393.77 | $1,578.41 | $1,605.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.60 / $464.26 / $1,985.84
| Professional | | $454.60 | $464.26 | $1,985.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.69 / $1,409.63 / $3,162.96
| Professional | | $433.69 | $1,409.63 | $3,162.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.19 / $3,228.56 / $21,581.96
| Professional | | $1,440.19 | $3,228.56 | $21,581.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.18 / $1,996.83 / $3,894.72
| Professional | | $1,360.18 | $1,996.83 | $3,894.72 |