- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.54 / $1,537.43 / $4,029.12
| Professional | | $687.54 | $1,537.43 | $4,029.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.01 / $1,508.94 / $3,091.63
| Professional | | $727.01 | $1,508.94 | $3,091.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.25 / $2,292.87 / $4,740.82
| Professional | | $1,441.25 | $2,292.87 | $4,740.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.17 / $3,534.19 / $6,123.31
| Professional | | $2,097.17 | $3,534.19 | $6,123.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,634.63 / $2,795.39 / $4,500.07
| Professional | | $1,634.63 | $2,795.39 | $4,500.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,097.17 / $3,581.33 / $4,516.99
| Professional | | $2,097.17 | $3,581.33 | $4,516.99 |