- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.97 / $1,292.40 / $1,498.35
| Professional | | $792.97 | $1,292.40 | $1,498.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.04 / $1,638.41 / $2,340.30
| Professional | | $1,266.04 | $1,638.41 | $2,340.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.43 / $1,798.02 / $2,653.75
| Professional | | $1,193.43 | $1,798.02 | $2,653.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,528.44 / $1,768.41 / $2,712.83
| Professional | | $1,528.44 | $1,768.41 | $2,712.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.97 / $1,102.71 / $1,498.35
| Professional | | $792.97 | $1,102.71 | $1,498.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.88 / $1,540.20 / $2,442.29
| Professional | | $1,018.88 | $1,540.20 | $2,442.29 |