- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.44 / $1,401.27 / $1,539.59
| Professional | | $365.44 | $1,401.27 | $1,539.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $760.10 / $983.70 / $3,379.75
| Professional | | $760.10 | $983.70 | $3,379.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $589.91 / $1,688.91 / $4,238.49
| Professional | | $589.91 | $1,688.91 | $4,238.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,318.98 / $3,471.14 / $4,046.41
| Professional | | $2,318.98 | $3,471.14 | $4,046.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,125.73 / $3,297.66 / $4,046.41
| Professional | | $2,125.73 | $3,297.66 | $4,046.41 |