- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $834.32 / $925.22 / $2,426.10
| Professional | | $834.32 | $925.22 | $2,426.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.56 / $1,135.56 / $1,297.94
| Professional | | $1,135.56 | $1,135.56 | $1,297.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.77 / $1,285.04 / $2,559.31
| Professional | | $866.77 | $1,285.04 | $2,559.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.49 / $1,385.18 / $2,182.56
| Professional | | $1,041.49 | $1,385.18 | $2,182.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $814.15 / $1,086.55 / $1,958.88
| Professional | | $814.15 | $1,086.55 | $1,958.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.40 / $1,197.71 / $1,477.68
| Professional | | $878.40 | $1,197.71 | $1,477.68 |