- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,122.02 / $2,089.30
| Professional | | $977.24 | $1,122.02 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,548.82 / $2,290.87
| Professional | | $977.24 | $1,548.82 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $2,398.83
| Professional | | $1,202.26 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,754.23
| Professional | | $1,202.26 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,951.21
| Professional | | $977.24 | $1,348.96 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $2,290.87
| Professional | | $1,000.00 | $1,380.38 | $2,290.87 |