- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.16 / $518.26 / $3,846.78
| Professional | | $299.16 | $518.26 | $3,846.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,183.75 / $3,183.75 / $5,580.75
| Professional | | $3,183.75 | $3,183.75 | $5,580.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.19 / $1,035.91 / $6,329.49
| Professional | | $360.19 | $1,035.91 | $6,329.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.60 / $3,914.71 / $6,698.43
| Professional | | $390.60 | $3,914.71 | $6,698.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.54 / $4,207.18 / $11,245.01
| Professional | | $734.54 | $4,207.18 | $11,245.01 |