- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.10 / $1,037.30 / $1,248.42
| Professional | | $829.10 | $1,037.30 | $1,248.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.89 / $1,345.74 / $1,911.75
| Professional | | $1,039.89 | $1,345.74 | $1,911.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.43 / $1,498.11 / $2,137.17
| Professional | | $1,018.43 | $1,498.11 | $2,137.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,248.55 / $1,444.57 / $2,216.05
| Professional | | $1,248.55 | $1,444.57 | $2,216.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.10 / $1,156.70 / $1,248.42
| Professional | | $829.10 | $1,156.70 | $1,248.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $882.72 / $1,387.91 / $1,979.86
| Professional | | $882.72 | $1,387.91 | $1,979.86 |