- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.36 / $991.36 / $1,200.94
| Professional | | $991.36 | $991.36 | $1,200.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,149.32 / $1,351.41 / $1,952.09
| Professional | | $1,149.32 | $1,351.41 | $1,952.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.07 / $1,451.31 / $2,241.52
| Professional | | $1,265.07 | $1,451.31 | $2,241.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.16 / $1,455.54 / $2,232.88
| Professional | | $1,130.16 | $1,455.54 | $2,232.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.36 / $991.36 / $1,200.94
| Professional | | $991.36 | $991.36 | $1,200.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.98 / $1,578.32 / $2,051.40
| Professional | | $1,188.98 | $1,578.32 | $2,051.40 |