- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.70 / $1,542.42 / $1,568.78
| Professional | | $422.70 | $1,542.42 | $1,568.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.54 / $497.90 / $1,932.49
| Professional | | $487.54 | $497.90 | $1,932.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.87 / $1,369.26 / $3,061.08
| Professional | | $466.87 | $1,369.26 | $3,061.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.67 / $3,091.68 / $20,549.21
| Professional | | $1,396.67 | $3,091.68 | $20,549.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.01 / $1,953.34 / $3,496.50
| Professional | | $1,289.01 | $1,953.34 | $3,496.50 |