- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.75 / $6,175.77 / $6,175.77
| Professional | | $921.75 | $6,175.77 | $6,175.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,531.88 / $2,337.28 / $3,353.89
| Professional | | $1,531.88 | $2,337.28 | $3,353.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,460.33 / $1,836.25 / $3,073.69
| Professional | | $1,460.33 | $1,836.25 | $3,073.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.87 / $1,525.35 / $2,656.11
| Professional | | $1,445.87 | $1,525.35 | $2,656.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.06 / $2,047.14 / $3,855.20
| Professional | | $1,217.06 | $2,047.14 | $3,855.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.26 / $1,991.56 / $3,537.87
| Professional | | $1,176.26 | $1,991.56 | $3,537.87 |