- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $2,041.74 / $6,918.31
| Professional | | $891.25 | $2,041.74 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,122.02 / $1,548.82
| Professional | | $1,023.29 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,235.94
| Professional | | $1,318.26 | $1,905.46 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $2,187.76
| Professional | | $1,000.00 | $1,230.27 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,290.87
| Professional | | $1,071.52 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $1,698.24
| Professional | | $831.76 | $1,412.54 | $1,698.24 |