- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $3,388.44 / $6,309.57
| Professional | | $724.44 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,000.00 / $1,548.82
| Professional | | $812.83 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $3,715.35 / $5,370.32
| Professional | | $724.44 | $3,715.35 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,862.09 / $7,079.46
| Professional | | $831.76 | $1,862.09 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,754.40 / $29,512.09
| Professional | | $3,388.44 | $5,754.40 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,754.23 / $6,025.60
| Professional | | $776.25 | $2,754.23 | $6,025.60 |