- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.18 / $892.06 / $1,023.70
| Professional | | $811.18 | $892.06 | $1,023.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.51 / $984.79 / $10,000.00
| Professional | | $881.51 | $984.79 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.27 / $1,466.18 / $2,732.27
| Professional | | $838.27 | $1,466.18 | $2,732.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.34 / $2,254.46 / $2,254.46
| Professional | | $1,796.34 | $2,254.46 | $2,254.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.14 / $2,429.31 / $2,729.55
| Professional | | $871.14 | $2,429.31 | $2,729.55 |