- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.78 / $1,210.50 / $1,343.36
| Professional | | $914.78 | $1,210.50 | $1,343.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.08 / $1,487.06 / $2,278.59
| Professional | | $1,149.08 | $1,487.06 | $2,278.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.49 / $1,745.10 / $2,462.17
| Professional | | $1,246.49 | $1,745.10 | $2,462.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,433.22 / $1,658.24 / $2,543.82
| Professional | | $1,433.22 | $1,658.24 | $2,543.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.78 / $1,343.36 / $1,688.66
| Professional | | $914.78 | $1,343.36 | $1,688.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.84 / $1,604.40 / $2,823.37
| Professional | | $1,074.84 | $1,604.40 | $2,823.37 |