- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.65 / $1,043.42 / $1,242.33
| Professional | | $819.65 | $1,043.42 | $1,242.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.35 / $1,341.17 / $1,901.85
| Professional | | $1,036.35 | $1,341.17 | $1,901.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,019.04 / $1,490.81 / $2,138.13
| Professional | | $1,019.04 | $1,490.81 | $2,138.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.13 / $1,435.99 / $2,202.88
| Professional | | $1,241.13 | $1,435.99 | $2,202.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.65 / $1,071.98 / $1,242.33
| Professional | | $819.65 | $1,071.98 | $1,242.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.79 / $1,273.76 / $1,705.93
| Professional | | $850.79 | $1,273.76 | $1,705.93 |