- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $995.37 / $1,086.83 / $6,270.76
| Professional | | $995.37 | $1,086.83 | $6,270.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.13 / $1,104.75 / $2,202.60
| Professional | | $1,077.13 | $1,104.75 | $2,202.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $650.75 / $1,193.28 / $1,961.87
| Professional | | $650.75 | $1,193.28 | $1,961.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.50 / $1,307.02 / $6,966.43
| Professional | | $828.50 | $1,307.02 | $6,966.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.50 / $1,303.21 / $1,643.36
| Professional | | $828.50 | $1,303.21 | $1,643.36 |