- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.85 / $1,050.36 / $1,263.61
| Professional | | $837.85 | $1,050.36 | $1,263.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.24 / $1,361.72 / $1,931.32
| Professional | | $1,052.24 | $1,361.72 | $1,931.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,029.29 / $1,516.35 / $2,163.19
| Professional | | $1,029.29 | $1,516.35 | $2,163.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.33 / $1,459.36 / $2,238.73
| Professional | | $1,261.33 | $1,459.36 | $2,238.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.85 / $1,155.36 / $1,263.61
| Professional | | $837.85 | $1,155.36 | $1,263.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.19 / $1,364.02 / $2,001.59
| Professional | | $963.19 | $1,364.02 | $2,001.59 |