- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.80 / $1,050.95 / $1,273.40
| Professional | | $848.80 | $1,050.95 | $1,273.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.87 / $1,289.20 / $1,825.51
| Professional | | $787.87 | $1,289.20 | $1,825.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.14 / $1,673.55 / $2,905.50
| Professional | | $1,112.14 | $1,673.55 | $2,905.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.43 / $1,615.36 / $3,088.26
| Professional | | $961.43 | $1,615.36 | $3,088.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.89 / $1,568.96 / $2,773.64
| Professional | | $1,141.89 | $1,568.96 | $2,773.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.38 / $814.29 / $977.15
| Professional | | $649.38 | $814.29 | $977.15 |