- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.55 / $1,172.72 / $1,416.08
| Professional | | $938.55 | $1,172.72 | $1,416.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,177.19 / $1,523.43 / $2,156.19
| Professional | | $1,177.19 | $1,523.43 | $2,156.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.10 / $1,699.30 / $2,418.14
| Professional | | $1,147.10 | $1,699.30 | $2,418.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.08 / $1,629.15 / $2,499.19
| Professional | | $1,408.08 | $1,629.15 | $2,499.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.55 / $1,295.60 / $1,416.08
| Professional | | $938.55 | $1,295.60 | $1,416.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $962.94 / $1,509.79 / $2,022.04
| Professional | | $962.94 | $1,509.79 | $2,022.04 |