- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.58 / $1,021.31 / $2,237.98
| Professional | | $871.58 | $1,021.31 | $2,237.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,058.86 / $6,058.86 / $6,058.86
| Professional | | $6,058.86 | $6,058.86 | $6,058.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.58 / $1,871.35 / $3,909.30
| Professional | | $990.58 | $1,871.35 | $3,909.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,164.36 / $2,550.01 / $3,909.30
| Professional | | $1,164.36 | $2,550.01 | $3,909.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,670.38 / $2,455.36 / $7,137.91
| Professional | | $1,670.38 | $2,455.36 | $7,137.91 |