- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.55 / $1,143.82 / $1,962.90
| Professional | | $869.55 | $1,143.82 | $1,962.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,747.82 / $2,644.49 / $3,782.07
| Professional | | $1,747.82 | $2,644.49 | $3,782.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,664.84 / $2,093.42 / $3,460.68
| Professional | | $1,664.84 | $2,093.42 | $3,460.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,648.36 / $1,738.98 / $3,028.09
| Professional | | $1,648.36 | $1,738.98 | $3,028.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.09 / $2,006.97 / $4,145.22
| Professional | | $1,198.09 | $2,006.97 | $4,145.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.48 / $1,952.48 / $3,626.19
| Professional | | $1,159.48 | $1,952.48 | $3,626.19 |