- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.57 / $908.57 / $6,124.01
| Professional | | $908.57 | $908.57 | $6,124.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.11 / $1,486.55 / $1,982.05
| Professional | | $872.11 | $1,486.55 | $1,982.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $2,237.58 / $2,983.54
| Professional | | $1,755.00 | $2,237.58 | $2,983.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.10 / $2,197.08 / $3,235.26
| Professional | | $1,428.10 | $2,197.08 | $3,235.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,783.48 / $2,284.77 / $2,983.54
| Professional | | $1,783.48 | $2,284.77 | $2,983.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.10 / $2,346.84 / $3,075.91
| Professional | | $1,428.10 | $2,346.84 | $3,075.91 |