- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.91 / $1,109.49 / $1,336.85
| Professional | | $886.91 | $1,109.49 | $1,336.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.59 / $1,439.84 / $2,040.51
| Professional | | $1,112.59 | $1,439.84 | $2,040.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.68 / $1,604.22 / $2,286.28
| Professional | | $1,086.68 | $1,604.22 | $2,286.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.64 / $1,541.86 / $2,365.30
| Professional | | $1,332.64 | $1,541.86 | $2,365.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $886.91 / $1,226.16 / $1,336.85
| Professional | | $886.91 | $1,226.16 | $1,336.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.01 / $1,424.11 / $2,114.79
| Professional | | $1,016.01 | $1,424.11 | $2,114.79 |