- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,096.48 / $2,344.23
| Professional | | $870.96 | $1,096.48 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,187.76 / $2,630.27
| Professional | | $1,023.29 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $2,951.21
| Professional | | $1,348.96 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,698.24 / $2,454.71
| Professional | | $79.43 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $2,630.27
| Professional | | $1,737.80 | $2,089.30 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,348.96 / $3,019.95
| Professional | | $1,071.52 | $1,348.96 | $3,019.95 |