- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,318.26 / $2,344.23
| Professional | | $1,047.13 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,621.81 / $2,238.72
| Professional | | $912.01 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,344.23
| Professional | | $1,230.27 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $2,089.30
| Professional | | $1,174.90 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $3,388.44
| Professional | | $1,047.13 | $1,445.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $2,290.87
| Professional | | $1,047.13 | $1,548.82 | $2,290.87 |