- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.56 / $935.56 / $1,625.95
| Professional | | $935.56 | $935.56 | $1,625.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.61 / $1,246.85 / $1,962.75
| Professional | | $1,087.61 | $1,246.85 | $1,962.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,139.91 / $1,400.25 / $2,006.10
| Professional | | $1,139.91 | $1,400.25 | $2,006.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.54 / $1,340.13 / $2,055.83
| Professional | | $1,040.54 | $1,340.13 | $2,055.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $935.56 / $935.56 / $1,625.95
| Professional | | $935.56 | $935.56 | $1,625.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.66 / $1,390.79 / $1,855.14
| Professional | | $1,140.66 | $1,390.79 | $1,855.14 |