- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.07 / $1,459.55 / $2,160.69
| Professional | | $789.07 | $1,459.55 | $2,160.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $733.33 / $1,245.81 / $1,950.76
| Professional | | $733.33 | $1,245.81 | $1,950.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.56 / $2,169.06 / $4,660.96
| Professional | | $1,045.56 | $2,169.06 | $4,660.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.87 / $1,978.00 / $4,465.06
| Professional | | $907.87 | $1,978.00 | $4,465.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.06 / $2,537.85 / $4,875.20
| Professional | | $1,763.06 | $2,537.85 | $4,875.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.30 / $836.23 / $1,655.50
| Professional | | $597.30 | $836.23 | $1,655.50 |