- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.22 / $1,328.69 / $1,721.97
| Professional | | $774.22 | $1,328.69 | $1,721.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.50 / $985.23 / $2,203.07
| Professional | | $717.50 | $985.23 | $2,203.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.16 / $1,593.04 / $2,618.01
| Professional | | $867.16 | $1,593.04 | $2,618.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,469.45 / $1,881.37 / $12,126.80
| Professional | | $1,469.45 | $1,881.37 | $12,126.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.63 / $1,778.81 / $2,604.03
| Professional | | $1,406.63 | $1,778.81 | $2,604.03 |