- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.54 / $1,452.41 / $5,482.23
| Professional | | $820.54 | $1,452.41 | $5,482.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.25 / $1,248.25 / $1,546.90
| Professional | | $1,248.25 | $1,248.25 | $1,546.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.97 / $1,248.25 / $1,854.15
| Professional | | $740.97 | $1,248.25 | $1,854.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.28 / $1,409.80 / $2,013.69
| Professional | | $922.28 | $1,409.80 | $2,013.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,410.65 / $1,706.60 / $1,878.40
| Professional | | $1,410.65 | $1,706.60 | $1,878.40 |