- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.47 / $1,014.08 / $1,219.27
| Professional | | $808.47 | $1,014.08 | $1,219.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.17 / $1,313.75 / $1,863.16
| Professional | | $1,015.17 | $1,313.75 | $1,863.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.41 / $1,463.12 / $2,087.64
| Professional | | $993.41 | $1,463.12 | $2,087.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.81 / $1,407.85 / $2,159.71
| Professional | | $1,216.81 | $1,407.85 | $2,159.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.47 / $1,114.75 / $1,219.27
| Professional | | $808.47 | $1,114.75 | $1,219.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $837.89 / $1,274.67 / $1,933.06
| Professional | | $837.89 | $1,274.67 | $1,933.06 |