- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $2,570.40
| Professional | | $831.76 | $1,047.13 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $1,995.26
| Professional | | $851.14 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $2,137.96
| Professional | | $1,047.13 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,258.93 / $2,398.83
| Professional | | $1,047.13 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $2,691.53
| Professional | | $912.01 | $1,288.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $1,949.84
| Professional | | $870.96 | $1,202.26 | $1,949.84 |