- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.65 / $1,040.88 / $1,299.09
| Professional | | $909.65 | $1,040.88 | $1,299.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,024.36 / $1,572.76 / $2,069.09
| Professional | | $1,024.36 | $1,572.76 | $2,069.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $1,536.60
| Professional | | $32.34 | $32.34 | $1,536.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.49 / $1,647.79 / $2,477.55
| Professional | | $1,080.49 | $1,647.79 | $2,477.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.22 / $1,556.65 / $2,470.48
| Professional | | $1,195.22 | $1,556.65 | $2,470.48 |