- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.02 / $1,273.10 / $1,651.25
| Professional | | $654.02 | $1,273.10 | $1,651.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,192.74 / $1,474.83 / $2,235.04
| Professional | | $1,192.74 | $1,474.83 | $2,235.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.76 / $1,630.47 / $2,397.15
| Professional | | $1,222.76 | $1,630.47 | $2,397.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,301.23 / $1,675.88 / $2,570.89
| Professional | | $1,301.23 | $1,675.88 | $2,570.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.65 / $1,273.10 / $1,824.20
| Professional | | $910.65 | $1,273.10 | $1,824.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,100.52 / $1,585.58 / $2,247.28
| Professional | | $1,100.52 | $1,585.58 | $2,247.28 |