- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $985.62 / $1,062.40 / $1,153.25
| Professional | | $985.62 | $1,062.40 | $1,153.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.00 / $1,234.31 / $1,355.29
| Professional | | $987.00 | $1,234.31 | $1,355.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.14 / $1,397.09 / $1,763.60
| Professional | | $1,026.14 | $1,397.09 | $1,763.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.62 / $1,210.80 / $9,057.00
| Professional | | $935.62 | $1,210.80 | $9,057.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.58 / $1,155.77 / $1,552.03
| Professional | | $880.58 | $1,155.77 | $1,552.03 |