- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $854.91 / $1,181.80 / $1,408.57
| Professional | | $854.91 | $1,181.80 | $1,408.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.19 / $1,399.18 / $1,921.22
| Professional | | $1,081.19 | $1,399.18 | $1,921.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.82 / $1,551.76 / $2,251.52
| Professional | | $1,018.82 | $1,551.76 | $2,251.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,254.74 / $1,451.73 / $2,227.04
| Professional | | $1,254.74 | $1,451.73 | $2,227.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.25 / $1,180.33 / $1,408.57
| Professional | | $1,090.25 | $1,180.33 | $1,408.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.52 / $1,646.42 / $2,016.89
| Professional | | $1,070.52 | $1,646.42 | $2,016.89 |