- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,584.89 / $2,818.38
| Professional | | $851.14 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $2,818.38
| Professional | | $1,148.15 | $1,819.70 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $2,818.38
| Professional | | $1,412.54 | $1,737.80 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,862.09 / $2,398.83
| Professional | | $1,548.82 | $1,862.09 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $3,630.78
| Professional | | $1,412.54 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,819.70 / $2,398.83
| Professional | | $1,288.25 | $1,819.70 | $2,398.83 |