- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.78 / $1,291.18 / $1,697.60
| Professional | | $355.78 | $1,291.18 | $1,697.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.70 / $1,411.40 / $4,134.12
| Professional | | $705.70 | $1,411.40 | $4,134.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.05 / $1,414.12 / $2,272.69
| Professional | | $811.05 | $1,414.12 | $2,272.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.10 / $1,562.96 / $4,217.07
| Professional | | $482.10 | $1,562.96 | $4,217.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.07 / $2,215.23 / $3,996.79
| Professional | | $1,432.07 | $2,215.23 | $3,996.79 |