- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $1,737.80
| Professional | | $912.01 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,187.76 / $2,570.40
| Professional | | $1,737.80 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,905.46 / $3,162.28
| Professional | | $1,148.15 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,949.84 / $2,818.38
| Professional | | $1,096.48 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,949.84 / $2,511.89
| Professional | | $1,096.48 | $1,949.84 | $2,511.89 |