- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.24 / $1,289.26 / $1,289.26
| Professional | | $822.24 | $1,289.26 | $1,289.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.45 / $1,388.23 / $2,060.17
| Professional | | $1,136.45 | $1,388.23 | $2,060.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.26 / $1,512.77 / $2,409.08
| Professional | | $1,130.26 | $1,512.77 | $2,409.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,190.51 / $1,533.28 / $2,352.13
| Professional | | $1,190.51 | $1,533.28 | $2,352.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.24 / $1,289.26 / $1,289.26
| Professional | | $822.24 | $1,289.26 | $1,289.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.20 / $1,485.30 / $2,183.11
| Professional | | $990.20 | $1,485.30 | $2,183.11 |