- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.63 / $1,096.11 / $1,312.71
| Professional | | $860.63 | $1,096.11 | $1,312.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,095.66 / $1,417.92 / $2,015.26
| Professional | | $1,095.66 | $1,417.92 | $2,015.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.86 / $1,575.26 / $2,254.48
| Professional | | $1,075.86 | $1,575.26 | $2,254.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.15 / $1,522.79 / $2,336.03
| Professional | | $1,316.15 | $1,522.79 | $2,336.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.59 / $1,180.72 / $1,673.84
| Professional | | $871.59 | $1,180.72 | $1,673.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.64 / $1,275.34 / $2,090.48
| Professional | | $892.64 | $1,275.34 | $2,090.48 |