- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.61 / $1,057.98 / $1,610.28
| Professional | | $913.61 | $1,057.98 | $1,610.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,061.51 / $1,485.17 / $2,297.61
| Professional | | $1,061.51 | $1,485.17 | $2,297.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.65 / $1,472.21 / $2,239.13
| Professional | | $1,059.65 | $1,472.21 | $2,239.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,057.00 / $9,057.00 / $9,057.00
| Professional | | $9,057.00 | $9,057.00 | $9,057.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.62 / $1,267.69 / $2,259.48
| Professional | | $935.62 | $1,267.69 | $2,259.48 |