- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.25 / $1,410.93 / $2,677.30
| Professional | | $382.25 | $1,410.93 | $2,677.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.75 / $1,222.03 / $3,567.60
| Professional | | $440.75 | $1,222.03 | $3,567.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $413.45 / $1,278.33 / $3,802.38
| Professional | | $413.45 | $1,278.33 | $3,802.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,219.62 / $21,581.96 / $22,229.42
| Professional | | $6,219.62 | $21,581.96 | $22,229.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,520.20 / $2,676.69 / $3,837.02
| Professional | | $1,520.20 | $2,676.69 | $3,837.02 |