- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.14 / $1,055.82 / $1,421.29
| Professional | | $813.14 | $1,055.82 | $1,421.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $817.26 / $1,149.33 / $2,081.17
| Professional | | $817.26 | $1,149.33 | $2,081.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.39 / $1,327.59 / $2,311.23
| Professional | | $440.39 | $1,327.59 | $2,311.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,966.43 / $6,966.43 / $9,003.00
| Professional | | $6,966.43 | $6,966.43 | $9,003.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.14 / $1,147.99 / $1,982.03
| Professional | | $350.14 | $1,147.99 | $1,982.03 |