- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.14 / $1,253.41 / $1,253.41
| Professional | | $928.14 | $1,253.41 | $1,253.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.69 / $1,081.22 / $1,582.65
| Professional | | $874.69 | $1,081.22 | $1,582.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.15 / $1,253.41 / $1,778.38
| Professional | | $1,030.15 | $1,253.41 | $1,778.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.23 / $1,032.15 / $1,606.03
| Professional | | $927.23 | $1,032.15 | $1,606.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.14 / $1,253.41 / $1,253.41
| Professional | | $928.14 | $1,253.41 | $1,253.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.35 / $1,177.57 / $1,522.73
| Professional | | $879.35 | $1,177.57 | $1,522.73 |