- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.79 / $1,108.91 / $1,108.91
| Professional | | $823.79 | $1,108.91 | $1,108.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,098.49 / $1,208.41 / $1,735.26
| Professional | | $1,098.49 | $1,208.41 | $1,735.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.49 / $1,363.41 / $1,941.68
| Professional | | $1,093.49 | $1,363.41 | $1,941.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,015.73 / $1,308.17 / $2,006.81
| Professional | | $1,015.73 | $1,308.17 | $2,006.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.79 / $1,108.91 / $1,108.91
| Professional | | $823.79 | $1,108.91 | $1,108.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.42 / $1,275.96 / $1,771.82
| Professional | | $973.42 | $1,275.96 | $1,771.82 |