- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.97 / $1,084.20 / $1,356.27
| Professional | | $962.97 | $1,084.20 | $1,356.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.66 / $1,363.56 / $1,904.18
| Professional | | $1,053.66 | $1,363.56 | $1,904.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.44 / $1,543.39 / $2,206.53
| Professional | | $1,013.44 | $1,543.39 | $2,206.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,243.60 / $1,438.86 / $2,207.28
| Professional | | $1,243.60 | $1,438.86 | $2,207.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.97 / $1,139.03 / $1,356.27
| Professional | | $962.97 | $1,139.03 | $1,356.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.76 / $1,555.70 / $2,089.09
| Professional | | $1,030.76 | $1,555.70 | $2,089.09 |