- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $1,778.28
| Professional | | $812.83 | $1,258.93 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,621.81 / $2,398.83
| Professional | | $1,023.29 | $1,621.81 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $2,454.71
| Professional | | $812.83 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $2,818.38
| Professional | | $1,258.93 | $1,513.56 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,412.54 / $3,019.95
| Professional | | $891.25 | $1,412.54 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,258.93 / $2,398.83
| Professional | | $851.14 | $1,258.93 | $2,398.83 |