- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.14 / $1,123.60 / $1,410.08
| Professional | | $940.14 | $1,123.60 | $1,410.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.95 / $1,517.94 / $2,147.92
| Professional | | $1,172.95 | $1,517.94 | $2,147.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.10 / $1,692.09 / $2,409.36
| Professional | | $1,143.10 | $1,692.09 | $2,409.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,402.72 / $1,622.95 / $2,489.69
| Professional | | $1,402.72 | $1,622.95 | $2,489.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.14 / $1,123.60 / $1,410.08
| Professional | | $940.14 | $1,123.60 | $1,410.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.66 / $1,550.40 / $2,226.66
| Professional | | $1,071.66 | $1,550.40 | $2,226.66 |