- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.34 / $1,152.85 / $1,574.89
| Professional | | $863.34 | $1,152.85 | $1,574.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.28 / $1,387.07 / $2,055.12
| Professional | | $1,214.28 | $1,387.07 | $2,055.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $919.67 / $1,429.35 / $2,139.11
| Professional | | $919.67 | $1,429.35 | $2,139.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.26 / $1,495.61 / $2,294.34
| Professional | | $1,161.26 | $1,495.61 | $2,294.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $929.82 / $1,152.85 / $1,532.05
| Professional | | $929.82 | $1,152.85 | $1,532.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.98 / $1,449.53 / $2,011.38
| Professional | | $998.98 | $1,449.53 | $2,011.38 |