- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,288.25 / $6,918.31
| Professional | | $891.25 | $1,288.25 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,089.30 / $3,467.37
| Professional | | $1,548.82 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $3,162.28
| Professional | | $1,548.82 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,511.89
| Professional | | $1,513.56 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,454.71 / $4,677.35
| Professional | | $1,479.11 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,454.71 / $3,981.07
| Professional | | $1,258.93 | $2,454.71 | $3,981.07 |