- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.60 / $1,240.07 / $4,989.51
| Professional | | $898.60 | $1,240.07 | $4,989.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,421.05 / $1,542.91 / $1,763.55
| Professional | | $1,421.05 | $1,542.91 | $1,763.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,607.93 / $1,999.86 / $3,224.73
| Professional | | $1,607.93 | $1,999.86 | $3,224.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.44 / $1,322.82 / $2,262.88
| Professional | | $1,025.44 | $1,322.82 | $2,262.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.10 / $1,476.79 / $2,257.14
| Professional | | $1,052.10 | $1,476.79 | $2,257.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.35 / $1,179.26 / $1,470.87
| Professional | | $820.35 | $1,179.26 | $1,470.87 |