- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.85 / $1,348.10 / $1,348.10
| Professional | | $983.85 | $1,348.10 | $1,348.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.73 / $1,488.76 / $2,150.46
| Professional | | $1,288.73 | $1,488.76 | $2,150.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.05 / $1,598.11 / $2,471.75
| Professional | | $1,265.05 | $1,598.11 | $2,471.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.17 / $1,606.25 / $2,464.08
| Professional | | $1,247.17 | $1,606.25 | $2,464.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.85 / $1,348.10 / $1,348.10
| Professional | | $983.85 | $1,348.10 | $1,348.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,085.57 / $1,632.37 / $2,260.79
| Professional | | $1,085.57 | $1,632.37 | $2,260.79 |