- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.80 / $1,062.09 / $1,168.09
| Professional | | $923.80 | $1,062.09 | $1,168.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.76 / $1,301.57 / $1,993.51
| Professional | | $1,005.76 | $1,301.57 | $1,993.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,090.61 / $1,510.48 / $2,154.29
| Professional | | $1,090.61 | $1,510.48 | $2,154.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.91 / $1,450.77 / $2,225.56
| Professional | | $1,253.91 | $1,450.77 | $2,225.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.80 / $1,086.93 / $1,168.09
| Professional | | $923.80 | $1,086.93 | $1,168.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.00 / $1,465.50 / $1,934.91
| Professional | | $977.00 | $1,465.50 | $1,934.91 |