- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $531.05 / $1,023.62 / $1,411.65
| Professional | | $531.05 | $1,023.62 | $1,411.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.94 / $1,141.16 / $1,730.16
| Professional | | $961.94 | $1,141.16 | $1,730.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.59 / $1,262.32 / $1,893.88
| Professional | | $973.59 | $1,262.32 | $1,893.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,006.85 / $1,296.73 / $1,989.25
| Professional | | $1,006.85 | $1,296.73 | $1,989.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.12 / $1,023.62 / $1,613.62
| Professional | | $809.12 | $1,023.62 | $1,613.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.58 / $1,275.19 / $1,737.86
| Professional | | $899.58 | $1,275.19 | $1,737.86 |