- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.09 / $887.48 / $4,409.97
| Professional | | $784.09 | $887.48 | $4,409.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.67 / $938.58 / $13,203.00
| Professional | | $860.67 | $938.58 | $13,203.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.08 / $3,411.99 / $12,010.79
| Professional | | $807.08 | $3,411.99 | $12,010.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.87 / $9,557.25 / $9,557.25
| Professional | | $1,753.87 | $9,557.25 | $9,557.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,939.85 / $5,318.53 / $11,571.24
| Professional | | $2,939.85 | $5,318.53 | $11,571.24 |