- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.68 / $981.96 / $4,870.93
| Professional | | $940.68 | $981.96 | $4,870.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.51 / $1,064.51 / $1,360.00
| Professional | | $1,064.51 | $1,064.51 | $1,360.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.08 / $1,244.82 / $2,876.78
| Professional | | $911.08 | $1,244.82 | $2,876.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.81 / $1,267.24 / $2,024.48
| Professional | | $952.81 | $1,267.24 | $2,024.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.02 / $1,133.46 / $1,859.50
| Professional | | $823.02 | $1,133.46 | $1,859.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.49 / $1,095.73 / $1,362.48
| Professional | | $735.49 | $1,095.73 | $1,362.48 |