- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.47 / $1,302.45 / $1,320.04
| Professional | | $944.47 | $1,302.45 | $1,320.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,599.98 / $1,886.03 / $3,944.27
| Professional | | $1,599.98 | $1,886.03 | $3,944.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,208.72 / $1,886.78 / $2,462.86
| Professional | | $1,208.72 | $1,886.78 | $2,462.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.83 / $1,635.62 / $2,462.86
| Professional | | $1,141.83 | $1,635.62 | $2,462.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,344.49 / $1,546.89 / $4,496.91
| Professional | | $1,344.49 | $1,546.89 | $4,496.91 |