- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.22 / $1,274.11 / $1,445.92
| Professional | | $705.22 | $1,274.11 | $1,445.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,514.71 / $2,575.08 / $2,575.08
| Professional | | $2,514.71 | $2,575.08 | $2,575.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.34 / $742.34 / $2,010.03
| Professional | | $742.34 | $742.34 | $2,010.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.06 / $1,743.36 / $3,528.00
| Professional | | $1,248.06 | $1,743.36 | $3,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.02 / $2,403.41 / $2,523.58
| Professional | | $558.02 | $2,403.41 | $2,523.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.12 / $829.73 / $1,262.21
| Professional | | $604.12 | $829.73 | $1,262.21 |