- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.13 / $1,084.23 / $1,304.69
| Professional | | $865.13 | $1,084.23 | $1,304.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.42 / $1,404.66 / $1,993.80
| Professional | | $1,085.42 | $1,404.66 | $1,993.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,062.86 / $1,565.63 / $2,232.26
| Professional | | $1,062.86 | $1,565.63 | $2,232.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,302.14 / $1,506.58 / $2,311.17
| Professional | | $1,302.14 | $1,506.58 | $2,311.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.13 / $1,195.74 / $1,304.69
| Professional | | $865.13 | $1,195.74 | $1,304.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.56 / $1,407.19 / $2,068.48
| Professional | | $991.56 | $1,407.19 | $2,068.48 |