- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $2,951.21
| Professional | | $912.01 | $1,174.90 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,187.76 / $3,388.44
| Professional | | $1,047.13 | $2,187.76 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,995.26 / $3,019.95
| Professional | | $1,230.27 | $1,995.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,659.59 / $2,238.72
| Professional | | $891.25 | $1,659.59 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,621.81 / $3,090.30
| Professional | | $1,000.00 | $1,621.81 | $3,090.30 |