- 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
- $977.24 / $1,949.84 / $5,888.44
| Professional | | $977.24 | $1,949.84 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,344.23 / $10,000.00
| Professional | | $1,148.15 | $2,344.23 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,623.41 / $8,128.31
| Professional | | $3,388.44 | $5,623.41 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,398.83 / $9,549.93
| Professional | | $831.76 | $2,398.83 | $9,549.93 |