- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $2,454.71
| Professional | | $933.25 | $1,174.90 | $2,454.71 |
- 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
- $1,071.52 / $1,412.54 / $2,238.72
| Professional | | $1,071.52 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,412.54 / $2,630.27
| Professional | | $1,174.90 | $1,412.54 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,288.25 / $2,818.38
| Professional | | $933.25 | $1,288.25 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,187.76
| Professional | | $870.96 | $1,318.26 | $2,187.76 |