- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,122.02 / $2,754.23
| Professional | | $891.25 | $1,122.02 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,445.44 / $2,137.96
| Professional | | $912.01 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,187.76
| Professional | | $1,122.02 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,511.89
| Professional | | $1,122.02 | $1,348.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,754.23
| Professional | | $954.99 | $1,380.38 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $2,089.30
| Professional | | $851.14 | $1,258.93 | $2,089.30 |