- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,621.81 / $2,511.89
| Professional | | $794.33 | $1,621.81 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,737.80 / $3,162.28
| Professional | | $831.76 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,570.40 / $2,754.23
| Professional | | $1,778.28 | $2,570.40 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,862.09 / $3,801.89
| Professional | | $1,047.13 | $1,862.09 | $3,801.89 |