- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,202.26 / $2,951.21
| Professional | | $977.24 | $1,202.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,621.81 / $2,238.72
| Professional | | $954.99 | $1,621.81 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $2,344.23
| Professional | | $1,148.15 | $1,513.56 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $2,691.53
| Professional | | $1,174.90 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,445.44 / $3,162.28
| Professional | | $1,047.13 | $1,445.44 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,238.72
| Professional | | $912.01 | $1,348.96 | $2,238.72 |