- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $980.79 / $1,052.95 / $4,924.72
| Professional | | $980.79 | $1,052.95 | $4,924.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.35 / $1,198.22 / $1,520.00
| Professional | | $1,139.35 | $1,198.22 | $1,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.57 / $1,266.18 / $3,107.83
| Professional | | $869.57 | $1,266.18 | $3,107.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.62 / $1,357.42 / $2,161.94
| Professional | | $1,020.62 | $1,357.42 | $2,161.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.14 / $1,068.45 / $1,953.31
| Professional | | $774.14 | $1,068.45 | $1,953.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $764.91 / $1,173.71 / $1,432.23
| Professional | | $764.91 | $1,173.71 | $1,432.23 |