- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.37 / $1,074.80 / $1,446.30
| Professional | | $880.37 | $1,074.80 | $1,446.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.52 / $1,243.15 / $1,825.15
| Professional | | $1,003.52 | $1,243.15 | $1,825.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.58 / $1,446.30 / $2,034.21
| Professional | | $1,188.58 | $1,446.30 | $2,034.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.08 / $1,186.72 / $1,846.54
| Professional | | $1,066.08 | $1,186.72 | $1,846.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.37 / $1,444.76 / $1,733.25
| Professional | | $880.37 | $1,444.76 | $1,733.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.10 / $1,365.64 / $1,765.91
| Professional | | $1,028.10 | $1,365.64 | $1,765.91 |