- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.68 / $1,180.34 / $1,310.43
| Professional | | $892.68 | $1,180.34 | $1,310.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,126.19 / $1,457.42 / $2,224.19
| Professional | | $1,126.19 | $1,457.42 | $2,224.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,216.22 / $1,703.77 / $2,402.39
| Professional | | $1,216.22 | $1,703.77 | $2,402.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.01 / $1,618.65 / $2,483.10
| Professional | | $1,399.01 | $1,618.65 | $2,483.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.68 / $1,310.43 / $1,612.94
| Professional | | $892.68 | $1,310.43 | $1,612.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.20 / $1,589.43 / $2,176.86
| Professional | | $1,073.20 | $1,589.43 | $2,176.86 |