- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.83 / $1,149.14 / $1,149.14
| Professional | | $842.83 | $1,149.14 | $1,149.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.53 / $1,241.38 / $1,781.16
| Professional | | $1,128.53 | $1,241.38 | $1,781.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,120.47 / $1,412.88 / $1,993.44
| Professional | | $1,120.47 | $1,412.88 | $1,993.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,048.69 / $1,350.62 / $2,071.92
| Professional | | $1,048.69 | $1,350.62 | $2,071.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.83 / $1,149.14 / $1,149.14
| Professional | | $842.83 | $1,149.14 | $1,149.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.34 / $1,350.62 / $1,816.40
| Professional | | $1,167.34 | $1,350.62 | $1,816.40 |