- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,818.38 / $5,754.40
| Professional | | $707.95 | $2,818.38 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $812.83 / $1,148.15
| Professional | | $660.69 | $812.83 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $977.24 / $1,174.90
| Professional | | $660.69 | $977.24 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $3,890.45 / $18,197.01
| Professional | | $912.01 | $3,890.45 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $562.34
| Professional | | $32.36 | $33.11 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,089.30 / $6,456.54
| Professional | | $776.25 | $2,089.30 | $6,456.54 |