- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.03 / $1,083.97 / $1,083.97
| Professional | | $819.03 | $1,083.97 | $1,083.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.92 / $1,228.59 / $1,774.67
| Professional | | $1,045.92 | $1,228.59 | $1,774.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.83 / $1,308.42 / $2,049.94
| Professional | | $1,096.83 | $1,308.42 | $2,049.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.95 / $1,336.80 / $2,050.71
| Professional | | $1,037.95 | $1,336.80 | $2,050.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.03 / $1,083.97 / $1,083.97
| Professional | | $819.03 | $1,083.97 | $1,083.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.04 / $1,336.45 / $1,883.57
| Professional | | $910.04 | $1,336.45 | $1,883.57 |