- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $1,819.70
| Professional | | $912.01 | $1,122.02 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,290.87 / $3,548.13
| Professional | | $1,548.82 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,884.03 / $4,365.16
| Professional | | $1,737.80 | $2,884.03 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $3,890.45
| Professional | | $1,862.09 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,187.76 / $6,456.54
| Professional | | $1,071.52 | $2,187.76 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,041.74 / $3,981.07
| Professional | | $1,071.52 | $2,041.74 | $3,981.07 |