- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.27 / $998.63 / $6,124.01
| Professional | | $889.27 | $998.63 | $6,124.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.60 / $1,161.82 / $1,452.28
| Professional | | $1,016.60 | $1,161.82 | $1,452.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.65 / $1,299.75 / $2,216.48
| Professional | | $920.65 | $1,299.75 | $2,216.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $964.11 / $1,247.47 / $10,915.46
| Professional | | $964.11 | $1,247.47 | $10,915.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.57 / $1,177.52 / $2,247.75
| Professional | | $940.57 | $1,177.52 | $2,247.75 |