- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.35 / $1,721.10 / $6,124.01
| Professional | | $892.35 | $1,721.10 | $6,124.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.70 / $1,560.70 / $2,098.76
| Professional | | $1,127.70 | $1,560.70 | $2,098.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.67 / $583.98 / $926.77
| Professional | | $93.67 | $583.98 | $926.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.94 / $1,655.09 / $3,096.31
| Professional | | $1,261.94 | $1,655.09 | $3,096.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.69 / $1,226.88 / $1,909.36
| Professional | | $954.69 | $1,226.88 | $1,909.36 |