- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.24 / $1,983.30 / $3,626.38
| Professional | | $855.24 | $1,983.30 | $3,626.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.16 / $1,520.73 / $4,906.00
| Professional | | $583.16 | $1,520.73 | $4,906.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.05 / $1,923.93 / $5,972.84
| Professional | | $715.05 | $1,923.93 | $5,972.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,229.62 / $2,229.62 / $3,210.03
| Professional | | $2,229.62 | $2,229.62 | $3,210.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.34 / $2,704.66 / $5,977.09
| Professional | | $1,623.34 | $2,704.66 | $5,977.09 |