- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.74 / $945.18 / $1,235.92
| Professional | | $836.74 | $945.18 | $1,235.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,027.88 / $1,330.20 / $1,888.41
| Professional | | $1,027.88 | $1,330.20 | $1,888.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.76 / $1,483.10 / $2,112.16
| Professional | | $1,005.76 | $1,483.10 | $2,112.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,233.30 / $1,426.93 / $2,188.98
| Professional | | $1,233.30 | $1,426.93 | $2,188.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.80 / $945.18 / $1,235.92
| Professional | | $819.80 | $945.18 | $1,235.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $849.90 / $1,331.47 / $1,955.71
| Professional | | $849.90 | $1,331.47 | $1,955.71 |