- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $3,388.44 / $5,754.40
| Professional | | $741.31 | $3,388.44 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $851.14 / $1,071.52
| Professional | | $758.58 | $851.14 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $2,511.89 / $7,585.78
| Professional | | $794.33 | $2,511.89 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $7,943.28
| Professional | | $3,890.45 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $2,041.74 / $7,079.46
| Professional | | $724.44 | $2,041.74 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $5,011.87 / $6,606.93
| Professional | | $812.83 | $5,011.87 | $6,606.93 |