- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.34 / $1,042.63 / $1,271.71
| Professional | | $936.34 | $1,042.63 | $1,271.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.94 / $1,362.63 / $1,926.64
| Professional | | $1,052.94 | $1,362.63 | $1,926.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.80 / $1,526.06 / $2,166.71
| Professional | | $1,018.80 | $1,526.06 | $2,166.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.50 / $1,450.30 / $2,224.84
| Professional | | $1,253.50 | $1,450.30 | $2,224.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $898.67 / $1,057.80 / $1,271.71
| Professional | | $898.67 | $1,057.80 | $1,271.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.50 / $1,381.87 / $1,950.45
| Professional | | $966.50 | $1,381.87 | $1,950.45 |