- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $3,981.07
| Professional | | $870.96 | $1,122.02 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $776.25
| Professional | | $741.31 | $741.31 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $2,754.23
| Professional | | $1,258.93 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $1,258.93
| Professional | | $891.25 | $1,023.29 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,819.70 / $3,801.89
| Professional | | $912.01 | $1,819.70 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,454.71
| Professional | | $1,096.48 | $1,548.82 | $2,454.71 |