- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $2,064.94 / $2,064.94
| Professional | | $455.43 | $2,064.94 | $2,064.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,202.60 / $2,477.92 / $2,824.84
| Professional | | $2,202.60 | $2,477.92 | $2,824.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.22 / $1,459.22 / $1,459.22
| Professional | | $1,459.22 | $1,459.22 | $1,459.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.25 / $3,303.90 / $4,129.88
| Professional | | $2,753.25 | $3,303.90 | $4,129.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.36 / $1,238.96 / $2,201.33
| Professional | | $1,156.36 | $1,238.96 | $2,201.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.63 / $1,376.63 / $1,376.63
| Professional | | $1,376.63 | $1,376.63 | $1,376.63 |