- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.09 / $1,055.52 / $1,270.08
| Professional | | $842.09 | $1,055.52 | $1,270.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.53 / $1,368.57 / $1,941.42
| Professional | | $1,057.53 | $1,368.57 | $1,941.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.59 / $1,524.11 / $2,173.94
| Professional | | $1,034.59 | $1,524.11 | $2,173.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,267.93 / $1,467.00 / $2,250.44
| Professional | | $1,267.93 | $1,467.00 | $2,250.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.09 / $1,165.95 / $1,270.08
| Professional | | $842.09 | $1,165.95 | $1,270.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.00 / $1,367.51 / $2,011.34
| Professional | | $873.00 | $1,367.51 | $2,011.34 |