- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $2,884.03
| Professional | | $794.33 | $1,148.15 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,071.52 / $1,230.27
| Professional | | $933.25 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $7,079.46
| Professional | | $1,047.13 | $1,905.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $1,995.26
| Professional | | $933.25 | $1,122.02 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,071.52 / $1,949.84
| Professional | | $691.83 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $1,621.81
| Professional | | $794.33 | $1,348.96 | $1,621.81 |