- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.57 / $1,306.32 / $1,587.28
| Professional | | $597.57 | $1,306.32 | $1,587.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.50 / $1,693.36 / $2,410.36
| Professional | | $1,308.50 | $1,693.36 | $2,410.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.77 / $1,865.87 / $2,692.83
| Professional | | $888.77 | $1,865.87 | $2,692.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,574.19 / $1,821.34 / $2,794.03
| Professional | | $1,574.19 | $1,821.34 | $2,794.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $597.57 / $1,154.91 / $1,587.28
| Professional | | $597.57 | $1,154.91 | $1,587.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.22 / $1,738.58 / $2,495.14
| Professional | | $1,039.22 | $1,738.58 | $2,495.14 |