- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,148.15 / $2,754.23
| Professional | | $912.01 | $1,148.15 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,137.96
| Professional | | $977.24 | $1,479.11 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $2,238.72
| Professional | | $1,148.15 | $1,479.11 | $2,238.72 |
- 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 / $1,380.38 / $2,951.21
| Professional | | $977.24 | $1,380.38 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,137.96
| Professional | | $891.25 | $1,258.93 | $2,137.96 |