- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.85 / $1,093.66 / $1,093.66
| Professional | | $810.85 | $1,093.66 | $1,093.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.97 / $1,189.06 / $1,704.10
| Professional | | $1,080.97 | $1,189.06 | $1,704.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.92 / $1,344.66 / $1,901.15
| Professional | | $1,073.92 | $1,344.66 | $1,901.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.48 / $1,283.38 / $1,968.77
| Professional | | $996.48 | $1,283.38 | $1,968.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $810.85 / $1,093.66 / $1,093.66
| Professional | | $810.85 | $1,093.66 | $1,093.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.01 / $1,304.30 / $1,740.10
| Professional | | $894.01 | $1,304.30 | $1,740.10 |