- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,884.03 / $5,888.44
| Professional | | $741.31 | $2,884.03 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,786.30 / $12,589.25
| Professional | | $1,412.54 | $4,786.30 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,786.30 / $16,982.44
| Professional | | $1,737.80 | $4,786.30 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,370.32 / $13,803.84
| Professional | | $1,737.80 | $5,370.32 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $8,317.64 / $22,908.68
| Professional | | $3,630.78 | $8,317.64 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $3,548.13 / $11,748.98
| Professional | | $977.24 | $3,548.13 | $11,748.98 |