- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $3,548.13 / $6,165.95
| Professional | | $794.33 | $3,548.13 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,479.11 / $2,137.96
| Professional | | $691.83 | $1,479.11 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,570.40 / $11,748.98
| Professional | | $1,047.13 | $2,570.40 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $3,311.31 / $9,120.11
| Professional | | $870.96 | $3,311.31 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $2,691.53 / $9,120.11
| Professional | | $912.01 | $2,691.53 | $9,120.11 |