- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.48 / $972.48 / $1,143.82
| Professional | | $972.48 | $972.48 | $1,143.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,060.44 / $2,519.46 / $3,149.34
| Professional | | $2,060.44 | $2,519.46 | $3,149.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,026.93 / $1,952.73 / $2,356.57
| Professional | | $1,026.93 | $1,952.73 | $2,356.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.00 / $2,356.57 / $2,957.99
| Professional | | $473.00 | $2,356.57 | $2,957.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.57 / $1,672.37 / $2,062.96
| Professional | | $1,095.57 | $1,672.37 | $2,062.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.77 / $1,301.82 / $2,077.76
| Professional | | $1,142.77 | $1,301.82 | $2,077.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,965.20 / $2,312.00 / $2,312.00
| Professional | | $1,965.20 | $2,312.00 | $2,312.00 |