- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.50 / $1,019.08 / $1,225.88
| Professional | | $813.50 | $1,019.08 | $1,225.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.47 / $1,320.61 / $1,872.62
| Professional | | $1,020.47 | $1,320.61 | $1,872.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.08 / $1,471.05 / $2,098.42
| Professional | | $998.08 | $1,471.05 | $2,098.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,223.00 / $1,415.01 / $2,170.69
| Professional | | $1,223.00 | $1,415.01 | $2,170.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.50 / $1,124.05 / $1,225.88
| Professional | | $813.50 | $1,124.05 | $1,225.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $931.67 / $1,281.96 / $1,942.96
| Professional | | $931.67 | $1,281.96 | $1,942.96 |