- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,454.71 / $5,128.61
| Professional | | $741.31 | $2,454.71 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,691.53 / $6,760.83
| Professional | | $724.44 | $2,691.53 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,691.53 / $3,801.89
| Professional | | $831.76 | $2,691.53 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $602.56 / $1,348.96
| Professional | | $32.36 | $602.56 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $2,290.87 / $5,495.41
| Professional | | $676.08 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $676.08 / $4,073.80
| Professional | | $602.56 | $676.08 | $4,073.80 |