- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.63 / $1,122.15 / $2,744.14
| Professional | | $938.63 | $1,122.15 | $2,744.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $970.88 / $1,957.93 / $2,732.87
| Professional | | $970.88 | $1,957.93 | $2,732.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.86 / $1,870.70 / $2,783.85
| Professional | | $1,325.86 | $1,870.70 | $2,783.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.90 / $1,606.79 / $1,974.50
| Professional | | $854.90 | $1,606.79 | $1,974.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.66 / $1,710.39 / $2,990.18
| Professional | | $943.66 | $1,710.39 | $2,990.18 |