- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.03 / $1,721.82 / $3,434.50
| Professional | | $886.03 | $1,721.82 | $3,434.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $946.26 / $1,756.15 / $3,001.60
| Professional | | $946.26 | $1,756.15 | $3,001.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.73 / $2,591.73 / $3,141.50
| Professional | | $1,198.73 | $2,591.73 | $3,141.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $2,238.46 / $2,816.13
| Professional | | $32.34 | $2,238.46 | $2,816.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.46 / $1,746.81 / $3,404.75
| Professional | | $1,251.46 | $1,746.81 | $3,404.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,851.36 / $2,679.60 / $3,906.44
| Professional | | $1,851.36 | $2,679.60 | $3,906.44 |