- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.14 / $818.35 / $1,287.29
| Professional | | $620.14 | $818.35 | $1,287.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.96 / $1,892.00 / $2,800.19
| Professional | | $1,127.96 | $1,892.00 | $2,800.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.81 / $2,075.11 / $3,379.60
| Professional | | $1,256.81 | $2,075.11 | $3,379.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.33 / $1,876.63 / $3,081.68
| Professional | | $1,172.33 | $1,876.63 | $3,081.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.17 / $1,603.39 / $3,285.05
| Professional | | $902.17 | $1,603.39 | $3,285.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.17 / $1,558.29 / $3,136.86
| Professional | | $902.17 | $1,558.29 | $3,136.86 |