- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $833.48 / $976.92 / $4,454.35
| Professional | | $833.48 | $976.92 | $4,454.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.58 / $1,041.95 / $1,350.00
| Professional | | $1,000.58 | $1,041.95 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.04 / $1,240.10 / $2,233.51
| Professional | | $826.04 | $1,240.10 | $2,233.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.31 / $1,200.07 / $1,928.03
| Professional | | $902.31 | $1,200.07 | $1,928.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.21 / $1,056.08 / $2,110.10
| Professional | | $756.21 | $1,056.08 | $2,110.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $703.68 / $1,037.66 / $1,266.17
| Professional | | $703.68 | $1,037.66 | $1,266.17 |