- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $773.71 / $960.30 / $1,473.25
| Professional | | $773.71 | $960.30 | $1,473.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $782.09 / $1,331.00 / $2,012.38
| Professional | | $782.09 | $1,331.00 | $2,012.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.41 / $1,281.67 / $2,078.98
| Professional | | $982.41 | $1,281.67 | $2,078.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,851.65 / $3,851.65 / $3,851.65
| Professional | | $3,851.65 | $3,851.65 | $3,851.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.07 / $704.28 / $1,306.25
| Professional | | $112.07 | $704.28 | $1,306.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.15 / $1,145.71 / $2,184.82
| Professional | | $843.15 | $1,145.71 | $2,184.82 |