- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.83 / $1,151.84 / $1,399.81
| Professional | | $779.83 | $1,151.84 | $1,399.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,157.78 / $1,498.31 / $2,123.82
| Professional | | $1,157.78 | $1,498.31 | $2,123.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.12 / $1,644.05 / $2,376.86
| Professional | | $954.12 | $1,644.05 | $2,376.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,387.05 / $1,604.82 / $2,461.88
| Professional | | $1,387.05 | $1,604.82 | $2,461.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.83 / $986.54 / $1,399.81
| Professional | | $779.83 | $986.54 | $1,399.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.77 / $1,216.07 / $2,198.59
| Professional | | $916.77 | $1,216.07 | $2,198.59 |