- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.60 / $1,216.08 / $1,375.59
| Professional | | $936.60 | $1,216.08 | $1,375.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.41 / $1,530.18 / $2,332.98
| Professional | | $1,182.41 | $1,530.18 | $2,332.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.00 / $1,786.25 / $2,520.46
| Professional | | $1,276.00 | $1,786.25 | $2,520.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,467.43 / $1,697.82 / $2,604.54
| Professional | | $1,467.43 | $1,697.82 | $2,604.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $936.60 / $1,375.59 / $1,747.79
| Professional | | $936.60 | $1,375.59 | $1,747.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.24 / $1,555.51 / $2,324.89
| Professional | | $1,047.24 | $1,555.51 | $2,324.89 |