- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.31 / $1,107.44 / $1,329.29
| Professional | | $880.31 | $1,107.44 | $1,329.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.54 / $1,430.70 / $2,031.04
| Professional | | $1,105.54 | $1,430.70 | $2,031.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.54 / $1,595.14 / $2,277.39
| Professional | | $1,083.54 | $1,595.14 | $2,277.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.46 / $1,534.71 / $2,354.33
| Professional | | $1,326.46 | $1,534.71 | $2,354.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.31 / $1,267.66 / $1,329.29
| Professional | | $880.31 | $1,267.66 | $1,329.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.26 / $1,429.40 / $2,095.77
| Professional | | $1,010.26 | $1,429.40 | $2,095.77 |