- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.06 / $1,258.40 / $3,261.45
| Professional | | $992.06 | $1,258.40 | $3,261.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,180.58 / $1,180.58 / $1,560.00
| Professional | | $1,180.58 | $1,180.58 | $1,560.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $958.14 / $1,499.43 / $3,156.76
| Professional | | $958.14 | $1,499.43 | $3,156.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.15 / $1,686.22 / $2,735.71
| Professional | | $1,307.15 | $1,686.22 | $2,735.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.07 / $1,330.85 / $2,299.17
| Professional | | $851.07 | $1,330.85 | $2,299.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.17 / $1,503.22 / $1,805.07
| Professional | | $987.17 | $1,503.22 | $1,805.07 |