- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,288.25 / $2,951.21
| Professional | | $870.96 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,511.89
| Professional | | $1,698.24 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $2,630.27
| Professional | | $1,513.56 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,511.89 / $8,912.51
| Professional | | $1,230.27 | $2,511.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,137.96 / $3,162.28
| Professional | | $1,230.27 | $2,137.96 | $3,162.28 |