- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.54 / $1,003.19 / $1,206.76
| Professional | | $875.54 | $1,003.19 | $1,206.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.76 / $1,223.29 / $2,244.34
| Professional | | $1,037.76 | $1,223.29 | $2,244.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $967.76 / $1,303.96 / $2,084.03
| Professional | | $967.76 | $1,303.96 | $2,084.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $910.47 / $1,303.96 / $2,084.03
| Professional | | $910.47 | $1,303.96 | $2,084.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,280.80 / $1,438.97 / $2,754.68
| Professional | | $1,280.80 | $1,438.97 | $2,754.68 |