- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.49 / $1,033.95 / $4,948.28
| Professional | | $958.49 | $1,033.95 | $4,948.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.74 / $1,117.74 / $1,400.00
| Professional | | $1,117.74 | $1,117.74 | $1,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.80 / $1,297.36 / $2,603.92
| Professional | | $903.80 | $1,297.36 | $2,603.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.98 / $1,396.79 / $2,254.48
| Professional | | $1,074.98 | $1,396.79 | $2,254.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.92 / $1,165.50 / $2,051.02
| Professional | | $835.92 | $1,165.50 | $2,051.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.82 / $1,236.23 / $1,483.08
| Professional | | $890.82 | $1,236.23 | $1,483.08 |