- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,230.27 / $1,659.59
| Professional | | $977.24 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,584.89 / $2,290.87
| Professional | | $977.24 | $1,584.89 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $1,380.38 / $2,398.83
| Professional | | $724.44 | $1,380.38 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,479.11 / $2,754.23
| Professional | | $1,230.27 | $1,479.11 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,951.21
| Professional | | $977.24 | $1,479.11 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,412.54 / $2,290.87
| Professional | | $912.01 | $1,412.54 | $2,290.87 |