- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.07 / $1,005.32 / $1,204.58
| Professional | | $799.07 | $1,005.32 | $1,204.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.88 / $1,299.14 / $1,848.64
| Professional | | $1,003.88 | $1,299.14 | $1,848.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.57 / $1,445.51 / $2,066.62
| Professional | | $987.57 | $1,445.51 | $2,066.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.33 / $1,396.88 / $2,142.89
| Professional | | $1,207.33 | $1,396.88 | $2,142.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.07 / $1,122.09 / $1,204.58
| Professional | | $799.07 | $1,122.09 | $1,204.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $915.49 / $1,275.64 / $1,920.13
| Professional | | $915.49 | $1,275.64 | $1,920.13 |