- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.68 / $1,061.65 / $1,278.80
| Professional | | $847.68 | $1,061.65 | $1,278.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,063.89 / $1,376.80 / $1,952.15
| Professional | | $1,063.89 | $1,376.80 | $1,952.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.95 / $1,534.56 / $2,186.96
| Professional | | $1,039.95 | $1,534.56 | $2,186.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.93 / $1,475.09 / $2,262.87
| Professional | | $1,274.93 | $1,475.09 | $2,262.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.68 / $1,211.25 / $1,278.80
| Professional | | $847.68 | $1,211.25 | $1,278.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.99 / $1,266.29 / $2,022.84
| Professional | | $870.99 | $1,266.29 | $2,022.84 |