- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.13 / $1,074.68 / $1,294.30
| Professional | | $858.13 | $1,074.68 | $1,294.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.59 / $1,393.24 / $1,975.60
| Professional | | $1,076.59 | $1,393.24 | $1,975.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.50 / $1,553.16 / $2,213.50
| Professional | | $1,052.50 | $1,553.16 | $2,213.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,290.19 / $1,492.75 / $2,289.96
| Professional | | $1,290.19 | $1,492.75 | $2,289.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.13 / $1,186.19 / $1,294.30
| Professional | | $858.13 | $1,186.19 | $1,294.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.14 / $1,427.00 / $2,207.77
| Professional | | $984.14 | $1,427.00 | $2,207.77 |