- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $2,818.38
| Professional | | $912.01 | $1,148.15 | $2,818.38 |
- 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 / $2,238.72
| Professional | | $1,148.15 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,630.27
| Professional | | $1,148.15 | $1,380.38 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $2,818.38
| Professional | | $977.24 | $1,412.54 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $2,137.96
| Professional | | $870.96 | $1,258.93 | $2,137.96 |