- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,398.83 / $5,754.40
| Professional | | $741.31 | $2,398.83 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,230.27 / $4,570.88
| Professional | | $707.95 | $1,230.27 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,737.80 / $6,760.83
| Professional | | $933.25 | $1,737.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $9,772.37
| Professional | | $3,890.45 | $3,890.45 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $2,290.87 / $5,248.07
| Professional | | $707.95 | $2,290.87 | $5,248.07 |