- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $976.39 / $1,176.25 / $5,138.06
| Professional | | $976.39 | $1,176.25 | $5,138.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.78 / $1,193.29 / $1,527.41
| Professional | | $1,159.78 | $1,193.29 | $1,527.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.44 / $1,409.58 / $2,578.48
| Professional | | $956.44 | $1,409.58 | $2,578.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.19 / $1,388.77 / $2,230.67
| Professional | | $1,044.19 | $1,388.77 | $2,230.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.44 / $1,190.02 / $2,198.69
| Professional | | $884.44 | $1,190.02 | $2,198.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.45 / $1,200.82 / $1,465.49
| Professional | | $808.45 | $1,200.82 | $1,465.49 |