- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.01 / $1,135.43 / $1,223.98
| Professional | | $954.01 | $1,135.43 | $1,223.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.73 / $2,131.60 / $2,499.40
| Professional | | $1,937.73 | $2,131.60 | $2,499.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.27 / $2,423.67 / $3,228.35
| Professional | | $1,256.27 | $2,423.67 | $3,228.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.07 / $2,199.17 / $3,028.39
| Professional | | $1,188.07 | $2,199.17 | $3,028.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.07 / $2,199.17 / $3,028.39
| Professional | | $1,188.07 | $2,199.17 | $3,028.39 |