- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.59 / $6,175.77 / $14,587.29
| Professional | | $882.59 | $6,175.77 | $14,587.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $941.27 / $1,157.94 / $1,641.85
| Professional | | $941.27 | $1,157.94 | $1,641.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.40 / $1,460.33 / $2,652.74
| Professional | | $807.40 | $1,460.33 | $2,652.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.99 / $1,198.68 / $6,302.04
| Professional | | $845.99 | $1,198.68 | $6,302.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.60 / $1,185.45 / $2,113.15
| Professional | | $841.60 | $1,185.45 | $2,113.15 |