- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.47 / $1,071.47 / $1,305.21
| Professional | | $1,071.47 | $1,071.47 | $1,305.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.74 / $805.63 / $1,075.23
| Professional | | $729.74 | $805.63 | $1,075.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.17 / $1,074.33 / $1,674.17
| Professional | | $819.17 | $1,074.33 | $1,674.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $625.80 / $805.99 / $1,236.43
| Professional | | $625.80 | $805.99 | $1,236.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.47 / $1,071.47 / $1,305.21
| Professional | | $1,071.47 | $1,071.47 | $1,305.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.94 / $1,483.58 / $1,923.16
| Professional | | $1,083.94 | $1,483.58 | $1,923.16 |