- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,090.30 / $5,128.61
| Professional | | $741.31 | $3,090.30 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $8,511.38 / $16,218.10
| Professional | | $758.58 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,137.96 / $10,471.29
| Professional | | $794.33 | $2,137.96 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,677.35 / $9,549.93
| Professional | | $1,737.80 | $4,677.35 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,570.40 / $9,772.37
| Professional | | $741.31 | $2,570.40 | $9,772.37 |