- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,951.21 / $6,760.83
| Professional | | $741.31 | $2,951.21 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,148.15 / $3,019.95
| Professional | | $691.83 | $1,148.15 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,238.72 / $8,709.64
| Professional | | $977.24 | $2,238.72 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $3,467.37 / $7,943.28
| Professional | | $870.96 | $3,467.37 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $3,162.28 / $10,964.78
| Professional | | $891.25 | $3,162.28 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,754.23 / $7,762.47
| Professional | | $831.76 | $2,754.23 | $7,762.47 |