- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.42 / $474.19 / $2,006.23
| Professional | | $398.42 | $474.19 | $2,006.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,006.23 / $2,364.91 / $5,089.77
| Professional | | $2,006.23 | $2,364.91 | $5,089.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $556.23 / $1,473.89 / $4,186.18
| Professional | | $556.23 | $1,473.89 | $4,186.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.62 / $2,144.51 / $3,418.35
| Professional | | $571.62 | $2,144.51 | $3,418.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,147.01 / $2,557.17 / $6,241.52
| Professional | | $2,147.01 | $2,557.17 | $6,241.52 |