- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.53 / $896.53 / $1,556.51
| Professional | | $896.53 | $896.53 | $1,556.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.58 / $1,192.93 / $1,888.02
| Professional | | $1,039.58 | $1,192.93 | $1,888.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.50 / $1,345.01 / $1,926.96
| Professional | | $1,059.50 | $1,345.01 | $1,926.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.92 / $1,289.10 / $1,977.56
| Professional | | $1,000.92 | $1,289.10 | $1,977.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.53 / $896.53 / $1,556.51
| Professional | | $896.53 | $896.53 | $1,556.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.92 / $1,273.26 / $1,783.98
| Professional | | $1,000.92 | $1,273.26 | $1,783.98 |