- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.92 / $997.92 / $997.92
| Professional | | $997.92 | $997.92 | $997.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.91 / $1,154.21 / $8,069.00
| Professional | | $1,058.91 | $1,154.21 | $8,069.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.96 / $1,628.21 / $2,800.95
| Professional | | $984.96 | $1,628.21 | $2,800.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.02 / $2,194.08 / $2,194.08
| Professional | | $1,067.02 | $2,194.08 | $2,194.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.13 / $1,668.96 / $2,691.50
| Professional | | $955.13 | $1,668.96 | $2,691.50 |