- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $2,137.96
| Professional | | $912.01 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $1,995.26
| Professional | | $870.96 | $1,230.27 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $2,511.89
| Professional | | $1,122.02 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,290.87
| Professional | | $1,737.80 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $33.11 / $33.11
| Professional | | $32.36 | $33.11 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,202.26 / $1,995.26
| Professional | | $954.99 | $1,202.26 | $1,995.26 |