- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $2,884.03
| Professional | | $933.25 | $1,174.90 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,513.56 / $2,238.72
| Professional | | $954.99 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $2,290.87
| Professional | | $1,174.90 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $2,630.27
| Professional | | $1,174.90 | $1,412.54 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,445.44 / $2,884.03
| Professional | | $1,000.00 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,187.76
| Professional | | $891.25 | $1,318.26 | $2,187.76 |