- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.20 / $927.20 / $1,693.51
| Professional | | $927.20 | $927.20 | $1,693.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.01 / $1,231.36 / $1,952.28
| Professional | | $1,076.01 | $1,231.36 | $1,952.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,150.25 / $1,393.41 / $1,996.30
| Professional | | $1,150.25 | $1,393.41 | $1,996.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.99 / $1,332.98 / $2,044.86
| Professional | | $1,034.99 | $1,332.98 | $2,044.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.20 / $927.20 / $1,693.51
| Professional | | $927.20 | $927.20 | $1,693.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.81 / $1,377.41 / $1,847.44
| Professional | | $1,023.81 | $1,377.41 | $1,847.44 |