- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.87 / $1,116.76 / $1,382.13
| Professional | | $942.87 | $1,116.76 | $1,382.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,146.83 / $1,484.15 / $2,132.03
| Professional | | $1,146.83 | $1,484.15 | $2,132.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.76 / $1,658.55 / $2,363.96
| Professional | | $1,138.76 | $1,658.55 | $2,363.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.41 / $1,611.02 / $2,471.39
| Professional | | $1,392.41 | $1,611.02 | $2,471.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.87 / $1,138.99 / $1,774.55
| Professional | | $942.87 | $1,138.99 | $1,774.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,049.83 / $1,485.09 / $2,212.92
| Professional | | $1,049.83 | $1,485.09 | $2,212.92 |