- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.84 / $1,217.82 / $1,470.39
| Professional | | $973.84 | $1,217.82 | $1,470.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.36 / $1,581.89 / $2,239.94
| Professional | | $1,222.36 | $1,581.89 | $2,239.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.98 / $1,764.47 / $2,510.94
| Professional | | $1,191.98 | $1,764.47 | $2,510.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,462.90 / $1,692.58 / $2,596.50
| Professional | | $1,462.90 | $1,692.58 | $2,596.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.84 / $1,394.67 / $1,470.39
| Professional | | $973.84 | $1,394.67 | $1,470.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,117.49 / $1,567.01 / $2,321.38
| Professional | | $1,117.49 | $1,567.01 | $2,321.38 |