- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $2,041.74
| Professional | | $912.01 | $1,288.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $2,089.30
| Professional | | $933.25 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $2,951.21
| Professional | | $1,380.38 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $4,365.16
| Professional | | $1,621.81 | $2,290.87 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $3,630.78
| Professional | | $912.01 | $1,412.54 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,479.11 / $3,388.44
| Professional | | $741.31 | $1,479.11 | $3,388.44 |