- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.88 / $1,307.39 / $2,573.05
| Professional | | $477.88 | $1,307.39 | $2,573.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.19 / $1,783.73 / $5,701.64
| Professional | | $489.19 | $1,783.73 | $5,701.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.15 / $2,018.06 / $2,481.29
| Professional | | $710.15 | $2,018.06 | $2,481.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.16 / $1,397.38 / $2,656.33
| Professional | | $309.16 | $1,397.38 | $2,656.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.52 / $2,753.70 / $4,359.81
| Professional | | $1,365.52 | $2,753.70 | $4,359.81 |