- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,023.29 / $2,884.03
| Professional | | $741.31 | $1,023.29 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,047.13 / $1,659.59
| Professional | | $851.14 | $1,047.13 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,047.13 / $1,445.44
| Professional | | $741.31 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,230.27 / $1,905.46
| Professional | | $831.76 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,548.82 / $10,232.93
| Professional | | $954.99 | $1,548.82 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $1,778.28
| Professional | | $794.33 | $1,096.48 | $1,778.28 |