- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.42 / $822.42 / $7,051.85
| Professional | | $822.42 | $822.42 | $7,051.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.61 / $763.37 / $822.43
| Professional | | $717.61 | $763.37 | $822.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.30 / $1,449.00 / $1,709.82
| Professional | | $1,014.30 | $1,449.00 | $1,709.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,456.25 / $1,456.25 / $1,456.25
| Professional | | $1,456.25 | $1,456.25 | $1,456.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.00 / $1,230.66 / $2,007.45
| Professional | | $923.00 | $1,230.66 | $2,007.45 |