- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.09 / $1,060.96 / $1,220.91
| Professional | | $887.09 | $1,060.96 | $1,220.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,016.94 / $1,316.04 / $1,864.42
| Professional | | $1,016.94 | $1,316.04 | $1,864.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.75 / $1,465.09 / $2,090.90
| Professional | | $993.75 | $1,465.09 | $2,090.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,217.64 / $1,408.81 / $2,161.19
| Professional | | $1,217.64 | $1,408.81 | $2,161.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.09 / $1,089.77 / $1,541.07
| Professional | | $887.09 | $1,089.77 | $1,541.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.78 / $1,337.64 / $1,934.57
| Professional | | $938.78 | $1,337.64 | $1,934.57 |