- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,445.44 / $2,630.27
| Professional | | $691.83 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $2,398.83
| Professional | | $1,096.48 | $1,096.48 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,737.80 / $2,884.03
| Professional | | $870.96 | $1,737.80 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $12,022.64
| Professional | | $1,584.89 | $2,290.87 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,479.11 / $2,570.40
| Professional | | $831.76 | $1,479.11 | $2,570.40 |