- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.76 / $846.06 / $1,773.84
| Professional | | $756.76 | $846.06 | $1,773.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.22 / $940.53 / $11,208.00
| Professional | | $822.22 | $940.53 | $11,208.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.09 / $2,009.65 / $4,831.16
| Professional | | $808.09 | $2,009.65 | $4,831.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.51 / $3,842.72 / $3,842.72
| Professional | | $1,675.51 | $3,842.72 | $3,842.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,425.57 / $2,691.56 / $4,652.49
| Professional | | $1,425.57 | $2,691.56 | $4,652.49 |