- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $846.87 / $1,116.42 / $1,213.35
| Professional | | $846.87 | $1,116.42 | $1,213.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.39 / $1,295.92 / $1,915.54
| Professional | | $1,001.39 | $1,295.92 | $1,915.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,032.88 / $1,497.44 / $2,266.11
| Professional | | $1,032.88 | $1,497.44 | $2,266.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.03 / $1,447.44 / $2,220.44
| Professional | | $1,251.03 | $1,447.44 | $2,220.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.48 / $1,088.97 / $1,213.35
| Professional | | $809.48 | $1,088.97 | $1,213.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.04 / $1,255.20 / $2,062.11
| Professional | | $922.04 | $1,255.20 | $2,062.11 |