- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,949.84
| Professional | | $812.83 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,288.25 / $1,698.24
| Professional | | $831.76 | $1,288.25 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,230.27 / $1,949.84
| Professional | | $1,023.29 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $1,819.70
| Professional | | $1,071.52 | $1,318.26 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,230.27 / $2,570.40
| Professional | | $812.83 | $1,230.27 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $1,905.46
| Professional | | $891.25 | $1,258.93 | $1,905.46 |