- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.90 / $1,011.20 / $1,215.20
| Professional | | $805.90 | $1,011.20 | $1,215.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.70 / $1,310.56 / $1,856.22
| Professional | | $1,012.70 | $1,310.56 | $1,856.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.46 / $1,480.44 / $2,082.13
| Professional | | $989.46 | $1,480.44 | $2,082.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.28 / $1,402.61 / $2,151.67
| Professional | | $1,212.28 | $1,402.61 | $2,151.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.90 / $1,183.08 / $1,215.20
| Professional | | $805.90 | $1,183.08 | $1,215.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.55 / $1,308.08 / $1,925.94
| Professional | | $923.55 | $1,308.08 | $1,925.94 |