- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,202.26 / $2,691.53
| Professional | | $977.24 | $1,202.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,905.46 / $2,691.53
| Professional | | $912.01 | $1,905.46 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,819.70 / $3,019.95
| Professional | | $1,202.26 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $2,398.83
| Professional | | $1,071.52 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,951.21
| Professional | | $1,096.48 | $1,584.89 | $2,951.21 |