- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.51 / $1,072.74 / $1,337.95
| Professional | | $942.51 | $1,072.74 | $1,337.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.18 / $1,352.59 / $1,880.22
| Professional | | $1,045.18 | $1,352.59 | $1,880.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.60 / $1,523.83 / $2,189.44
| Professional | | $1,001.60 | $1,523.83 | $2,189.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.53 / $1,420.25 / $2,178.73
| Professional | | $1,227.53 | $1,420.25 | $2,178.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.51 / $1,109.40 / $1,337.95
| Professional | | $942.51 | $1,109.40 | $1,337.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.81 / $1,521.03 / $2,037.09
| Professional | | $909.81 | $1,521.03 | $2,037.09 |