- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.78 / $1,107.44 / $1,332.96
| Professional | | $883.78 | $1,107.44 | $1,332.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.42 / $1,435.72 / $2,036.72
| Professional | | $1,109.42 | $1,435.72 | $2,036.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.43 / $1,599.56 / $2,280.77
| Professional | | $1,085.43 | $1,599.56 | $2,280.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.17 / $1,539.01 / $2,360.92
| Professional | | $1,330.17 | $1,539.01 | $2,360.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.78 / $1,213.91 / $1,332.96
| Professional | | $883.78 | $1,213.91 | $1,332.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.04 / $1,435.14 / $1,901.33
| Professional | | $1,014.04 | $1,435.14 | $1,901.33 |