- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,548.13 / $6,760.83
| Professional | | $741.31 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $3,467.37 / $6,606.93
| Professional | | $933.25 | $3,467.37 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,398.83 / $6,165.95
| Professional | | $794.33 | $2,398.83 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,011.87 / $29,512.09
| Professional | | $3,235.94 | $5,011.87 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,454.71 / $5,495.41
| Professional | | $741.31 | $2,454.71 | $5,495.41 |