- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $3,311.31
| Professional | | $691.83 | $1,513.56 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $977.24 / $1,479.11
| Professional | | $776.25 | $977.24 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,621.81 / $2,290.87
| Professional | | $691.83 | $1,621.81 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,621.81 / $3,162.28
| Professional | | $794.33 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,454.71 / $12,022.64
| Professional | | $1,584.89 | $2,454.71 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,479.11 / $2,630.27
| Professional | | $741.31 | $1,479.11 | $2,630.27 |