- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,548.82 / $2,089.30
| Professional | | $407.38 | $1,548.82 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $4,073.80 / $8,128.31
| Professional | | $562.34 | $4,073.80 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $1,288.25 / $5,248.07
| Professional | | $398.11 | $1,288.25 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $3,311.31
| Professional | | $1,548.82 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,348.96 / $3,630.78
| Professional | | $371.54 | $1,348.96 | $3,630.78 |