- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $2,369.57 / $2,590.71
| Professional | | $477.00 | $2,369.57 | $2,590.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,527.54 / $2,843.48 / $3,241.57
| Professional | | $2,527.54 | $2,843.48 | $3,241.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,674.49 / $1,674.49 / $1,674.49
| Professional | | $1,674.49 | $1,674.49 | $1,674.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,791.30 / $4,739.13
| Professional | | $3,159.42 | $3,791.30 | $4,739.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,421.74 / $2,843.48
| Professional | | $1,326.96 | $1,421.74 | $2,843.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.71 / $1,579.71 / $1,579.71
| Professional | | $1,579.71 | $1,579.71 | $1,579.71 |