- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,445.44 / $2,454.71
| Professional | | $436.52 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $933.25 / $2,454.71
| Professional | | $426.58 | $933.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,023.29 / $3,090.30
| Professional | | $537.03 | $1,023.29 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $1,949.84 / $3,090.30
| Professional | | $501.19 | $1,949.84 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $1,479.11 / $4,466.84
| Professional | | $457.09 | $1,479.11 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,698.24 / $3,235.94
| Professional | | $537.03 | $1,698.24 | $3,235.94 |