- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $2,754.23
| Professional | | $933.25 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,479.11 / $2,187.76
| Professional | | $933.25 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $2,290.87
| Professional | | $1,148.15 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,570.40
| Professional | | $1,148.15 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,818.38
| Professional | | $1,023.29 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,238.72
| Professional | | $891.25 | $1,318.26 | $2,238.72 |