- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.43 / $838.19 / $838.19
| Professional | | $807.43 | $838.19 | $838.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.31 / $1,407.31 / $1,407.31
| Professional | | $1,407.31 | $1,407.31 | $1,407.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.95 / $1,391.56 / $1,421.13
| Professional | | $1,034.95 | $1,391.56 | $1,421.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.89 / $1,443.89 / $1,443.89
| Professional | | $1,443.89 | $1,443.89 | $1,443.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,409.45 / $8,883.41
| Professional | | $1,040.02 | $1,409.45 | $8,883.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.53 / $1,409.45 / $2,027.43
| Professional | | $984.53 | $1,409.45 | $2,027.43 |