- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $1,949.84
| Professional | | $891.25 | $1,071.52 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,318.26 / $1,778.28
| Professional | | $741.31 | $1,318.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $1,905.46
| Professional | | $1,000.00 | $1,174.90 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,202.26 / $1,737.80
| Professional | | $977.24 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $2,754.23
| Professional | | $912.01 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $1,905.46
| Professional | | $870.96 | $1,230.27 | $1,905.46 |