- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,570.40
| Professional | | $912.01 | $1,258.93 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,862.09
| Professional | | $1,584.89 | $1,584.89 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,412.54 / $2,344.23
| Professional | | $891.25 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $1,698.24
| Professional | | $1,071.52 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $4,265.80
| Professional | | $1,202.26 | $1,445.44 | $4,265.80 |