- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.12 / $1,009.46 / $1,125.29
| Professional | | $767.12 | $1,009.46 | $1,125.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $965.50 / $1,249.47 / $1,920.11
| Professional | | $965.50 | $1,249.47 | $1,920.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,038.35 / $1,455.11 / $2,070.14
| Professional | | $1,038.35 | $1,455.11 | $2,070.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,207.75 / $1,397.37 / $2,143.64
| Professional | | $1,207.75 | $1,397.37 | $2,143.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.12 / $1,125.29 / $1,278.13
| Professional | | $767.12 | $1,125.29 | $1,278.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.25 / $1,350.36 / $2,068.38
| Professional | | $888.25 | $1,350.36 | $2,068.38 |