- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.58 / $962.97 / $4,936.88
| Professional | | $930.58 | $962.97 | $4,936.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.77 / $1,525.20 / $2,033.59
| Professional | | $894.77 | $1,525.20 | $2,033.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,601.00 / $2,296.01 / $3,112.87
| Professional | | $1,601.00 | $2,296.01 | $3,112.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.92 / $2,187.90 / $3,111.17
| Professional | | $1,322.92 | $2,187.90 | $3,111.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.03 / $2,227.13 / $3,112.87
| Professional | | $1,751.03 | $2,227.13 | $3,112.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,322.92 / $2,237.11 / $2,849.36
| Professional | | $1,322.92 | $2,237.11 | $2,849.36 |