- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.62 / $935.96 / $4,637.97
| Professional | | $895.62 | $935.96 | $4,637.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.28 / $1,013.28 / $1,158.18
| Professional | | $1,013.28 | $1,013.28 | $1,158.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.04 / $1,186.93 / $2,739.78
| Professional | | $853.04 | $1,186.93 | $2,739.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $907.96 / $1,207.58 / $1,928.61
| Professional | | $907.96 | $1,207.58 | $1,928.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.32 / $1,100.69 / $2,105.87
| Professional | | $783.32 | $1,100.69 | $2,105.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.24 / $1,044.15 / $1,298.31
| Professional | | $731.24 | $1,044.15 | $1,298.31 |