- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.87 / $1,194.95 / $1,194.95
| Professional | | $789.87 | $1,194.95 | $1,194.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,132.28 / $1,332.49 / $1,924.73
| Professional | | $1,132.28 | $1,332.49 | $1,924.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,159.00 / $1,426.99 / $2,229.87
| Professional | | $1,159.00 | $1,426.99 | $2,229.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.01 / $1,432.18 / $2,197.04
| Professional | | $1,112.01 | $1,432.18 | $2,197.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $789.87 / $1,194.95 / $1,194.95
| Professional | | $789.87 | $1,194.95 | $1,194.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.37 / $1,243.72 / $2,029.88
| Professional | | $930.37 | $1,243.72 | $2,029.88 |