- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.09 / $1,238.52 / $1,477.93
| Professional | | $938.09 | $1,238.52 | $1,477.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.60 / $1,548.55 / $2,154.91
| Professional | | $1,196.60 | $1,548.55 | $2,154.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.73 / $1,759.50 / $2,524.53
| Professional | | $1,143.73 | $1,759.50 | $2,524.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.43 / $1,627.24 / $2,496.27
| Professional | | $1,406.43 | $1,627.24 | $2,496.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.09 / $1,318.64 / $1,477.93
| Professional | | $938.09 | $1,318.64 | $1,477.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,105.71 / $1,541.17 / $2,292.33
| Professional | | $1,105.71 | $1,541.17 | $2,292.33 |