- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $2,454.71
| Professional | | $912.01 | $1,148.15 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $2,187.76
| Professional | | $1,071.52 | $1,412.54 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $2,511.89
| Professional | | $1,096.48 | $1,479.11 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $5,248.07
| Professional | | $891.25 | $1,258.93 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $891.25 / $1,778.28
| Professional | | $891.25 | $891.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,691.53
| Professional | | $1,122.02 | $1,548.82 | $2,691.53 |