- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.25 / $1,118.17 / $1,622.40
| Professional | | $952.25 | $1,118.17 | $1,622.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.47 / $1,301.89 / $2,209.17
| Professional | | $909.47 | $1,301.89 | $2,209.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.23 / $1,506.74 / $2,534.35
| Professional | | $1,187.23 | $1,506.74 | $2,534.35 |
- 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
- $113.57 / $709.90 / $1,302.34
| Professional | | $113.57 | $709.90 | $1,302.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.46 / $1,291.33 / $2,157.29
| Professional | | $950.46 | $1,291.33 | $2,157.29 |