- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $759.81 / $773.49 / $4,760.43
| Professional | | $759.81 | $773.49 | $4,760.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.36 / $1,101.03 / $1,535.93
| Professional | | $1,066.36 | $1,101.03 | $1,535.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.22 / $1,234.33 / $2,347.37
| Professional | | $837.22 | $1,234.33 | $2,347.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $944.69 / $1,256.44 / $2,031.92
| Professional | | $944.69 | $1,256.44 | $2,031.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.22 / $1,125.59 / $2,396.02
| Professional | | $802.22 | $1,125.59 | $2,396.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.39 / $1,206.64 / $1,340.72
| Professional | | $1,086.39 | $1,206.64 | $1,340.72 |