- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.25 / $1,155.08 / $1,378.35
| Professional | | $757.25 | $1,155.08 | $1,378.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,152.14 / $1,491.00 / $2,116.88
| Professional | | $1,152.14 | $1,491.00 | $2,116.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.43 / $1,654.01 / $2,373.08
| Professional | | $1,131.43 | $1,654.01 | $2,373.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,382.52 / $1,599.58 / $2,453.83
| Professional | | $1,382.52 | $1,599.58 | $2,453.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.25 / $1,206.69 / $1,378.35
| Professional | | $757.25 | $1,206.69 | $1,378.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.89 / $1,297.74 / $1,691.78
| Professional | | $922.89 | $1,297.74 | $1,691.78 |