- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,318.26 / $2,754.23
| Professional | | $977.24 | $1,318.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,995.26
| Professional | | $1,698.24 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,454.71
| Professional | | $977.24 | $1,479.11 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $1,778.28
| Professional | | $1,122.02 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $4,466.84
| Professional | | $1,258.93 | $1,513.56 | $4,466.84 |