- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,323.00 / $1,613.67 / $9,124.90
| Professional | | $1,323.00 | $1,613.67 | $9,124.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,270.49 / $1,758.00 / $2,496.36
| Professional | | $1,270.49 | $1,758.00 | $2,496.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.50 / $1,028.90 / $1,272.34
| Professional | | $871.50 | $1,028.90 | $1,272.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,026.52 / $2,528.06 / $6,815.57
| Professional | | $2,026.52 | $2,528.06 | $6,815.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.85 / $1,480.30 / $2,613.84
| Professional | | $1,091.85 | $1,480.30 | $2,613.84 |