- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $636.28 / $805.93 / $1,167.43
| Professional | | $636.28 | $805.93 | $1,167.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.74 / $1,900.12 / $2,734.50
| Professional | | $1,158.74 | $1,900.12 | $2,734.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.16 / $2,127.38 / $3,320.61
| Professional | | $1,261.16 | $2,127.38 | $3,320.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.42 / $1,909.13 / $3,027.89
| Professional | | $1,200.42 | $1,909.13 | $3,027.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.00 / $1,571.13 / $4,686.47
| Professional | | $850.00 | $1,571.13 | $4,686.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $825.23 / $1,552.88 / $3,003.14
| Professional | | $825.23 | $1,552.88 | $3,003.14 |