- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $3,235.94 / $6,309.57
| Professional | | $724.44 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,949.84 / $4,677.35
| Professional | | $933.25 | $1,949.84 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,884.03 / $6,606.93
| Professional | | $851.14 | $2,884.03 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $3,235.94
| Professional | | $32.36 | $33.11 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $2,884.03 / $7,244.36
| Professional | | $870.96 | $2,884.03 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,951.21 / $6,606.93
| Professional | | $977.24 | $2,951.21 | $6,606.93 |