- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.56 / $992.06 / $4,935.28
| Professional | | $951.56 | $992.06 | $4,935.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.39 / $1,077.39 / $1,231.46
| Professional | | $1,077.39 | $1,077.39 | $1,231.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $905.80 / $1,256.23 / $2,906.10
| Professional | | $905.80 | $1,256.23 | $2,906.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.24 / $1,281.10 / $2,046.85
| Professional | | $963.24 | $1,281.10 | $2,046.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.26 / $1,132.08 / $1,885.29
| Professional | | $815.26 | $1,132.08 | $1,885.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.49 / $1,107.73 / $1,377.53
| Professional | | $750.49 | $1,107.73 | $1,377.53 |