- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,737.80 / $3,090.30
| Professional | | $933.25 | $1,737.80 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,995.26 / $3,019.95
| Professional | | $1,258.93 | $1,995.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $3,019.95
| Professional | | $1,584.89 | $1,905.46 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,041.74 / $2,630.27
| Professional | | $1,698.24 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $4,073.80
| Professional | | $1,548.82 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $2,630.27
| Professional | | $1,412.54 | $1,995.26 | $2,630.27 |