- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.04 / $1,047.51 / $2,807.32
| Professional | | $977.04 | $1,047.51 | $2,807.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.08 / $1,101.52 / $1,360.00
| Professional | | $1,092.08 | $1,101.52 | $1,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.17 / $1,272.59 / $2,996.64
| Professional | | $917.17 | $1,272.59 | $2,996.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.00 / $1,294.08 / $2,114.17
| Professional | | $973.00 | $1,294.08 | $2,114.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.25 / $1,127.83 / $1,931.35
| Professional | | $824.25 | $1,127.83 | $1,931.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.99 / $1,118.95 / $1,391.39
| Professional | | $764.99 | $1,118.95 | $1,391.39 |