- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.77 / $1,137.68 / $1,371.44
| Professional | | $909.77 | $1,137.68 | $1,371.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.19 / $1,476.83 / $2,091.96
| Professional | | $1,141.19 | $1,476.83 | $2,091.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.21 / $1,645.73 / $2,344.83
| Professional | | $1,113.21 | $1,645.73 | $2,344.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.62 / $1,580.02 / $2,423.84
| Professional | | $1,365.62 | $1,580.02 | $2,423.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.77 / $1,258.46 / $1,371.44
| Professional | | $909.77 | $1,258.46 | $1,371.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.29 / $1,506.39 / $2,339.34
| Professional | | $1,042.29 | $1,506.39 | $2,339.34 |