- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.11 / $3,820.44 / $6,333.58
| Professional | | $415.11 | $3,820.44 | $6,333.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,418.56 / $2,591.31 / $5,225.89
| Professional | | $2,418.56 | $2,591.31 | $5,225.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,685.25 / $4,001.50 / $5,314.20
| Professional | | $2,685.25 | $4,001.50 | $5,314.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,503.78 / $4,850.68 / $9,212.04
| Professional | | $3,503.78 | $4,850.68 | $9,212.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.05 / $2,763.96 / $2,763.96
| Professional | | $278.05 | $2,763.96 | $2,763.96 |