- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.50 / $984.13 / $1,239.73
| Professional | | $841.50 | $984.13 | $1,239.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.00 / $1,440.36 / $2,209.12
| Professional | | $1,113.00 | $1,440.36 | $2,209.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.30 / $1,603.10 / $2,296.46
| Professional | | $1,161.30 | $1,603.10 | $2,296.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.53 / $1,607.69 / $2,466.28
| Professional | | $1,389.53 | $1,607.69 | $2,466.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $841.50 / $1,226.05 / $1,239.73
| Professional | | $841.50 | $1,226.05 | $1,239.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $877.97 / $1,291.65 / $2,135.96
| Professional | | $877.97 | $1,291.65 | $2,135.96 |