- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.26 / $1,102.63 / $1,324.74
| Professional | | $967.26 | $1,102.63 | $1,324.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,102.35 / $1,426.59 / $2,029.78
| Professional | | $1,102.35 | $1,426.59 | $2,029.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.34 / $1,589.69 / $2,268.26
| Professional | | $1,083.34 | $1,589.69 | $2,268.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.64 / $1,533.77 / $2,352.88
| Professional | | $1,325.64 | $1,533.77 | $2,352.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.26 / $1,324.74 / $1,428.96
| Professional | | $967.26 | $1,324.74 | $1,428.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.80 / $1,451.67 / $1,877.16
| Professional | | $1,006.80 | $1,451.67 | $1,877.16 |