- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.75 / $1,581.93 / $2,844.80
| Professional | | $761.75 | $1,581.93 | $2,844.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.96 / $1,695.55 / $4,005.10
| Professional | | $1,260.96 | $1,695.55 | $4,005.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.08 / $1,058.08 / $2,431.23
| Professional | | $1,058.08 | $1,058.08 | $2,431.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.20 / $1,963.34 / $5,275.17
| Professional | | $814.20 | $1,963.34 | $5,275.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.72 / $2,445.89 / $3,590.86
| Professional | | $1,748.72 | $2,445.89 | $3,590.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.18 / $1,784.85 / $3,435.14
| Professional | | $1,384.18 | $1,784.85 | $3,435.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.66 / $2,181.92 / $5,435.31
| Professional | | $875.66 | $2,181.92 | $5,435.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.65 / $2,104.63 / $5,291.66
| Professional | | $1,415.65 | $2,104.63 | $5,291.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.18 / $2,025.18 / $3,435.14
| Professional | | $1,384.18 | $2,025.18 | $3,435.14 |