- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.18 / $1,044.83 / $1,543.14
| Professional | | $819.18 | $1,044.83 | $1,543.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.78 / $1,228.90 / $1,798.20
| Professional | | $1,018.78 | $1,228.90 | $1,798.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.78 / $1,673.68 / $2,445.79
| Professional | | $1,155.78 | $1,673.68 | $2,445.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,173.11 / $1,504.12 / $2,669.66
| Professional | | $1,173.11 | $1,504.12 | $2,669.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.10 / $1,067.84 / $1,543.14
| Professional | | $787.10 | $1,067.84 | $1,543.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,125.86 / $1,554.05 / $2,469.13
| Professional | | $1,125.86 | $1,554.05 | $2,469.13 |