- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.29 / $1,076.61 / $1,325.29
| Professional | | $852.29 | $1,076.61 | $1,325.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.89 / $1,369.03 / $1,931.96
| Professional | | $1,057.89 | $1,369.03 | $1,931.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,218.35 / $1,590.35 / $2,210.80
| Professional | | $1,218.35 | $1,590.35 | $2,210.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.74 / $1,459.83 / $2,239.46
| Professional | | $1,261.74 | $1,459.83 | $2,239.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.76 / $1,143.88 / $1,325.29
| Professional | | $919.76 | $1,143.88 | $1,325.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.22 / $1,404.58 / $2,027.74
| Professional | | $1,007.22 | $1,404.58 | $2,027.74 |