- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,454.71
| Professional | | $812.83 | $1,288.25 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,548.82 / $2,041.74
| Professional | | $794.33 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $2,398.83
| Professional | | $1,047.13 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,584.89 / $2,238.72
| Professional | | $1,318.26 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,513.56 / $3,019.95
| Professional | | $812.83 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,398.83
| Professional | | $977.24 | $1,380.38 | $2,398.83 |