- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $806.33 / $1,058.45 / $2,365.21
| Professional | | $806.33 | $1,058.45 | $2,365.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.05 / $1,592.52 / $2,299.91
| Professional | | $824.05 | $1,592.52 | $2,299.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.81 / $1,685.49 / $2,422.52
| Professional | | $1,159.81 | $1,685.49 | $2,422.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $843.68 / $1,482.70 / $1,948.95
| Professional | | $843.68 | $1,482.70 | $1,948.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.62 / $1,709.30 / $2,888.65
| Professional | | $911.62 | $1,709.30 | $2,888.65 |