- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $2,454.71
| Professional | | $794.33 | $1,071.52 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $1,949.84
| Professional | | $870.96 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,348.96 / $2,041.74
| Professional | | $1,023.29 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,318.26 / $2,454.71
| Professional | | $1,096.48 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $2,691.53
| Professional | | $851.14 | $1,258.93 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,148.15 / $1,949.84
| Professional | | $776.25 | $1,148.15 | $1,949.84 |