- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.09 / $1,645.55 / $2,618.16
| Professional | | $745.09 | $1,645.55 | $2,618.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,452.52 / $2,755.88 / $5,571.20
| Professional | | $1,452.52 | $2,755.88 | $5,571.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,611.36 / $3,205.10 / $6,785.02
| Professional | | $1,611.36 | $3,205.10 | $6,785.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,595.41 / $2,976.56 / $5,673.17
| Professional | | $1,595.41 | $2,976.56 | $5,673.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.04 / $3,534.19 / $7,037.78
| Professional | | $1,811.04 | $3,534.19 | $7,037.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,811.04 / $3,448.01 / $6,573.93
| Professional | | $1,811.04 | $3,448.01 | $6,573.93 |