- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,621.81 / $2,818.38
| Professional | | $870.96 | $1,621.81 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,862.09 / $2,818.38
| Professional | | $1,148.15 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,778.28 / $2,818.38
| Professional | | $1,584.89 | $1,778.28 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $2,398.83
| Professional | | $1,548.82 | $1,819.70 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,995.26 / $3,890.45
| Professional | | $1,479.11 | $1,995.26 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $2,454.71
| Professional | | $1,412.54 | $1,862.09 | $2,454.71 |