- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.28 / $965.93 / $1,575.09
| Professional | | $728.28 | $965.93 | $1,575.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.62 / $1,298.64 / $1,975.15
| Professional | | $905.62 | $1,298.64 | $1,975.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.93 / $1,276.28 / $2,097.05
| Professional | | $906.93 | $1,276.28 | $2,097.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,173.00 / $10,316.10 / $10,316.10
| Professional | | $10,173.00 | $10,316.10 | $10,316.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.35 / $1,147.71 / $2,172.81
| Professional | | $900.35 | $1,147.71 | $2,172.81 |