- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.86 / $1,078.99 / $1,298.13
| Professional | | $841.86 | $1,078.99 | $1,298.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.24 / $1,361.72 / $1,925.01
| Professional | | $1,052.24 | $1,361.72 | $1,925.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.69 / $1,557.75 / $2,203.76
| Professional | | $1,025.69 | $1,557.75 | $2,203.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.21 / $1,454.59 / $2,231.42
| Professional | | $1,257.21 | $1,454.59 | $2,231.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.86 / $1,186.42 / $1,298.13
| Professional | | $841.86 | $1,186.42 | $1,298.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.58 / $1,352.40 / $2,030.43
| Professional | | $986.58 | $1,352.40 | $2,030.43 |