- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.87 / $1,063.21 / $1,273.15
| Professional | | $845.87 | $1,063.21 | $1,273.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.83 / $1,375.42 / $1,952.78
| Professional | | $1,062.83 | $1,375.42 | $1,952.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.31 / $1,527.78 / $2,186.94
| Professional | | $1,042.31 | $1,527.78 | $2,186.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.34 / $1,475.58 / $2,263.62
| Professional | | $1,275.34 | $1,475.58 | $2,263.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.87 / $1,196.39 / $1,273.15
| Professional | | $845.87 | $1,196.39 | $1,273.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.49 / $1,329.92 / $2,047.45
| Professional | | $874.49 | $1,329.92 | $2,047.45 |