- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,047.13 / $2,570.40
| Professional | | $831.76 | $1,047.13 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,348.96 / $1,949.84
| Professional | | $891.25 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,041.74
| Professional | | $1,047.13 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $2,511.89
| Professional | | $1,122.02 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,288.25 / $3,162.28
| Professional | | $912.01 | $1,288.25 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $1,995.26
| Professional | | $812.83 | $1,148.15 | $1,995.26 |