- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.90 / $1,045.48 / $1,267.17
| Professional | | $837.90 | $1,045.48 | $1,267.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.77 / $1,358.53 / $1,927.54
| Professional | | $1,049.77 | $1,358.53 | $1,927.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.36 / $1,520.61 / $2,156.21
| Professional | | $1,025.36 | $1,520.61 | $2,156.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.85 / $1,456.50 / $2,234.35
| Professional | | $1,258.85 | $1,456.50 | $2,234.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.47 / $1,122.14 / $1,267.17
| Professional | | $848.47 | $1,122.14 | $1,267.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.37 / $1,267.83 / $2,234.35
| Professional | | $874.37 | $1,267.83 | $2,234.35 |