- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.47 / $1,210.76 / $2,904.82
| Professional | | $902.47 | $1,210.76 | $2,904.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.63 / $1,945.35 / $3,114.33
| Professional | | $982.63 | $1,945.35 | $3,114.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.92 / $1,984.98 / $2,963.82
| Professional | | $1,286.92 | $1,984.98 | $2,963.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.38 / $1,651.12 / $1,921.65
| Professional | | $833.38 | $1,651.12 | $1,921.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.26 / $1,793.01 / $3,166.50
| Professional | | $1,019.26 | $1,793.01 | $3,166.50 |