- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.94 / $872.94 / $1,515.31
| Professional | | $872.94 | $872.94 | $1,515.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.96 / $1,161.76 / $1,832.84
| Professional | | $1,013.96 | $1,161.76 | $1,832.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.43 / $1,307.82 / $1,873.69
| Professional | | $1,052.43 | $1,307.82 | $1,873.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.67 / $1,251.42 / $1,919.75
| Professional | | $971.67 | $1,251.42 | $1,919.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.94 / $872.94 / $1,515.31
| Professional | | $872.94 | $872.94 | $1,515.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,057.30 / $1,370.10 / $1,916.51
| Professional | | $1,057.30 | $1,370.10 | $1,916.51 |