- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.31 / $895.31 / $1,147.06
| Professional | | $895.31 | $895.31 | $1,147.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.66 / $1,211.36 / $1,838.47
| Professional | | $1,029.66 | $1,211.36 | $1,838.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.85 / $1,560.57 / $2,410.76
| Professional | | $866.85 | $1,560.57 | $2,410.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.88 / $1,671.21 / $2,475.77
| Professional | | $1,394.88 | $1,671.21 | $2,475.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $895.31 / $1,068.32 / $1,147.06
| Professional | | $895.31 | $1,068.32 | $1,147.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.75 / $1,538.44 / $2,475.77
| Professional | | $1,087.75 | $1,538.44 | $2,475.77 |