- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.15 / $1,084.63 / $1,306.84
| Professional | | $864.15 | $1,084.63 | $1,306.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,082.25 / $1,400.56 / $1,989.39
| Professional | | $1,082.25 | $1,400.56 | $1,989.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.61 / $1,568.22 / $2,231.53
| Professional | | $1,059.61 | $1,568.22 | $2,231.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.25 / $1,503.23 / $2,306.04
| Professional | | $1,299.25 | $1,503.23 | $2,306.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $864.15 / $1,206.88 / $1,306.84
| Professional | | $864.15 | $1,206.88 | $1,306.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.21 / $1,388.42 / $2,066.30
| Professional | | $993.21 | $1,388.42 | $2,066.30 |