- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $952.00 / $1,194.68 / $5,277.36
| Professional | | $952.00 | $1,194.68 | $5,277.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,396.06 / $1,396.06 / $3,756.51
| Professional | | $1,396.06 | $1,396.06 | $3,756.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $807.40 / $1,492.59 / $3,756.51
| Professional | | $807.40 | $1,492.59 | $3,756.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,113.88 / $1,539.78 / $3,756.51
| Professional | | $1,113.88 | $1,539.78 | $3,756.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.38 / $1,411.94 / $4,610.70
| Professional | | $1,109.38 | $1,411.94 | $4,610.70 |