- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.43 / $1,269.73 / $1,580.78
| Professional | | $349.43 | $1,269.73 | $1,580.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.38 / $1,483.18 / $2,899.16
| Professional | | $440.38 | $1,483.18 | $2,899.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.75 / $1,280.60 / $3,616.61
| Professional | | $396.75 | $1,280.60 | $3,616.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,782.08 / $3,317.02 / $20,549.21
| Professional | | $1,782.08 | $3,317.02 | $20,549.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,551.85 / $2,596.96 / $3,933.43
| Professional | | $1,551.85 | $2,596.96 | $3,933.43 |