- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.45 / $3,252.88 / $3,590.48
| Professional | | $961.45 | $3,252.88 | $3,590.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,604.39 / $1,604.39 / $1,738.52
| Professional | | $1,604.39 | $1,604.39 | $1,738.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,862.20 / $5,871.86 / $8,137.67
| Professional | | $3,862.20 | $5,871.86 | $8,137.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,336.75 / $6,174.62 / $9,472.20
| Professional | | $5,336.75 | $6,174.62 | $9,472.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.45 / $2,675.87 / $3,590.48
| Professional | | $961.45 | $2,675.87 | $3,590.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.69 / $3,159.02 / $6,783.29
| Professional | | $2,416.69 | $3,159.02 | $6,783.29 |