- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.97 / $1,057.98 / $1,529.83
| Professional | | $962.97 | $1,057.98 | $1,529.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.73 / $1,125.66 / $1,883.66
| Professional | | $927.73 | $1,125.66 | $1,883.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.78 / $1,480.71 / $2,545.36
| Professional | | $1,155.78 | $1,480.71 | $2,545.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,851.65 / $3,851.65 / $3,851.65
| Professional | | $3,851.65 | $3,851.65 | $3,851.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.30 / $731.11 / $1,330.99
| Professional | | $75.30 | $731.11 | $1,330.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.58 / $1,177.55 / $2,218.11
| Professional | | $880.58 | $1,177.55 | $2,218.11 |