- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.56 / $1,608.67 / $2,075.42
| Professional | | $369.56 | $1,608.67 | $2,075.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,158.13 / $1,158.13 / $1,452.67
| Professional | | $1,158.13 | $1,158.13 | $1,452.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.40 / $2,179.80 / $2,675.40
| Professional | | $839.40 | $2,179.80 | $2,675.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.85 / $1,827.00 / $2,726.00
| Professional | | $1,391.85 | $1,827.00 | $2,726.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $590.78 / $1,669.50 / $2,778.00
| Professional | | $590.78 | $1,669.50 | $2,778.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.76 / $1,162.14 / $2,686.08
| Professional | | $1,131.76 | $1,162.14 | $2,686.08 |