- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $3,162.28 / $6,309.57
| Professional | | $776.25 | $3,162.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $13,182.57
| Professional | | $851.14 | $3,162.28 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,454.71 / $10,000.00
| Professional | | $851.14 | $2,454.71 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,754.40 / $7,943.28
| Professional | | $4,786.30 | $5,754.40 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $3,311.31 / $10,232.93
| Professional | | $831.76 | $3,311.31 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $13,182.57
| Professional | | $851.14 | $3,162.28 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,630.27 / $10,000.00
| Professional | | $891.25 | $2,630.27 | $10,000.00 |