- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.23 / $2,095.91 / $3,275.40
| Professional | | $642.23 | $2,095.91 | $3,275.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.17 / $899.33 / $2,603.33
| Professional | | $454.17 | $899.33 | $2,603.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.94 / $1,617.88 / $4,213.66
| Professional | | $508.94 | $1,617.88 | $4,213.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.74 / $1,475.65 / $4,554.59
| Professional | | $487.74 | $1,475.65 | $4,554.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,088.66 / $3,078.86 / $9,030.45
| Professional | | $2,088.66 | $3,078.86 | $9,030.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.68 / $1,228.76 / $2,327.27
| Professional | | $325.68 | $1,228.76 | $2,327.27 |