- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.11 / $1,078.83 / $1,348.09
| Professional | | $804.11 | $1,078.83 | $1,348.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.79 / $1,535.57 / $2,404.40
| Professional | | $1,186.79 | $1,535.57 | $2,404.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,266.40 / $1,743.22 / $2,511.71
| Professional | | $1,266.40 | $1,743.22 | $2,511.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.36 / $1,749.80 / $2,684.29
| Professional | | $1,512.36 | $1,749.80 | $2,684.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.11 / $1,183.51 / $1,348.09
| Professional | | $804.11 | $1,183.51 | $1,348.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $987.82 / $1,379.69 / $2,335.33
| Professional | | $987.82 | $1,379.69 | $2,335.33 |