- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,148.15 / $2,454.71
| Professional | | $831.76 | $1,148.15 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $2,398.83
| Professional | | $1,096.48 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $25,118.86
| Professional | | $1,479.11 | $2,344.23 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $7,943.28
| Professional | | $1,479.11 | $1,621.81 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,047.13 / $1,071.52
| Professional | | $933.25 | $1,047.13 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $3,090.30
| Professional | | $1,548.82 | $1,995.26 | $3,090.30 |