- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.57 / $915.52 / $5,554.84
| Professional | | $906.57 | $915.52 | $5,554.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.75 / $1,193.39 / $1,364.04
| Professional | | $1,190.75 | $1,193.39 | $1,364.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.36 / $1,400.57 / $2,776.40
| Professional | | $927.36 | $1,400.57 | $2,776.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.91 / $1,470.51 / $2,386.76
| Professional | | $1,116.91 | $1,470.51 | $2,386.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.93 / $1,233.30 / $2,123.04
| Professional | | $877.93 | $1,233.30 | $2,123.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.45 / $1,284.45 / $1,592.00
| Professional | | $938.45 | $1,284.45 | $1,592.00 |