- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.17 / $1,317.72 / $1,317.72
| Professional | | $988.17 | $1,317.72 | $1,317.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,285.39 / $1,418.32 / $2,048.71
| Professional | | $1,285.39 | $1,418.32 | $2,048.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.50 / $1,531.37 / $2,333.67
| Professional | | $1,332.50 | $1,531.37 | $2,333.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.26 / $1,534.24 / $2,353.61
| Professional | | $1,191.26 | $1,534.24 | $2,353.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.17 / $1,317.72 / $1,317.72
| Professional | | $988.17 | $1,317.72 | $1,317.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.07 / $1,534.24 / $2,138.33
| Professional | | $1,189.07 | $1,534.24 | $2,138.33 |