- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.67 / $1,056.23 / $1,056.23
| Professional | | $962.67 | $1,056.23 | $1,056.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.37 / $1,278.13 / $1,699.91
| Professional | | $733.37 | $1,278.13 | $1,699.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $430.19 / $977.10 / $5,288.92
| Professional | | $430.19 | $977.10 | $5,288.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.30 / $2,583.16 / $2,583.16
| Professional | | $1,160.30 | $2,583.16 | $2,583.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.51 / $2,455.36 / $3,662.28
| Professional | | $730.51 | $2,455.36 | $3,662.28 |