- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.58 / $1,003.77 / $1,596.91
| Professional | | $930.58 | $1,003.77 | $1,596.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,355.66 / $1,594.89 / $1,594.89
| Professional | | $1,355.66 | $1,594.89 | $1,594.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.21 / $1,465.79 / $2,275.19
| Professional | | $1,062.21 | $1,465.79 | $2,275.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.73 / $1,335.20 / $9,057.00
| Professional | | $1,100.73 | $1,335.20 | $9,057.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.73 / $1,283.24 / $1,747.19
| Professional | | $1,100.73 | $1,283.24 | $1,747.19 |