- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.58 / $1,071.07 / $1,256.40
| Professional | | $912.58 | $1,071.07 | $1,256.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.89 / $1,353.50 / $1,918.70
| Professional | | $1,045.89 | $1,353.50 | $1,918.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.34 / $1,507.67 / $2,149.94
| Professional | | $1,022.34 | $1,507.67 | $2,149.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.08 / $1,449.83 / $2,224.11
| Professional | | $1,253.08 | $1,449.83 | $2,224.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.58 / $1,189.41 / $1,583.16
| Professional | | $912.58 | $1,189.41 | $1,583.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.86 / $1,384.10 / $1,988.80
| Professional | | $954.86 | $1,384.10 | $1,988.80 |