- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.82 / $882.59 / $1,758.95
| Professional | | $863.82 | $882.59 | $1,758.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.98 / $1,566.79 / $1,881.38
| Professional | | $1,396.98 | $1,566.79 | $1,881.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.11 / $1,323.30 / $1,323.30
| Professional | | $1,101.11 | $1,323.30 | $1,323.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.43 / $1,460.47 / $1,924.84
| Professional | | $894.43 | $1,460.47 | $1,924.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $705.29 / $1,125.69 / $2,152.01
| Professional | | $705.29 | $1,125.69 | $2,152.01 |