- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.70 / $3,404.42 / $5,873.58
| Professional | | $220.70 | $3,404.42 | $5,873.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.48 / $3,913.04 / $6,470.68
| Professional | | $262.48 | $3,913.04 | $6,470.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.07 / $2,963.66 / $3,711.68
| Professional | | $2,310.07 | $2,963.66 | $3,711.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.64 / $465.76 / $6,782.91
| Professional | | $303.64 | $465.76 | $6,782.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,650.88 / $4,478.01 / $8,475.37
| Professional | | $3,650.88 | $4,478.01 | $8,475.37 |