- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.57 / $6,175.77 / $6,175.77
| Professional | | $926.57 | $6,175.77 | $6,175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,419.66 / $1,419.66 / $1,419.66
| Professional | | $1,419.66 | $1,419.66 | $1,419.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.24 / $1,408.00 / $1,408.00
| Professional | | $1,268.24 | $1,408.00 | $1,408.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.14 / $1,175.66 / $6,302.04
| Professional | | $1,018.14 | $1,175.66 | $6,302.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.72 / $1,095.35 / $1,980.98
| Professional | | $975.72 | $1,095.35 | $1,980.98 |