- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $1,412.54 / $3,388.44
| Professional | | $389.05 | $1,412.54 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,659.59 / $4,570.88
| Professional | | $724.44 | $1,659.59 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $2,041.74 / $6,025.60
| Professional | | $645.65 | $2,041.74 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,801.89
| Professional | | $2,818.38 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $1,445.44 / $4,365.16
| Professional | | $446.68 | $1,445.44 | $4,365.16 |