- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.14 / $1,145.83 / $1,284.34
| Professional | | $865.14 | $1,145.83 | $1,284.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,092.86 / $1,414.31 / $1,979.29
| Professional | | $1,092.86 | $1,414.31 | $1,979.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.22 / $1,542.78 / $2,281.79
| Professional | | $1,060.22 | $1,542.78 | $2,281.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,292.66 / $1,495.61 / $2,294.34
| Professional | | $1,292.66 | $1,495.61 | $2,294.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.75 / $1,145.83 / $1,284.34
| Professional | | $959.75 | $1,145.83 | $1,284.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.56 / $1,563.34 / $2,085.21
| Professional | | $979.56 | $1,563.34 | $2,085.21 |