- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.30 / $1,300.40 / $1,300.40
| Professional | | $922.30 | $1,300.40 | $1,300.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.83 / $1,448.26 / $2,091.96
| Professional | | $1,232.83 | $1,448.26 | $2,091.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.75 / $1,551.28 / $2,418.55
| Professional | | $1,222.75 | $1,551.28 | $2,418.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,209.77 / $1,558.09 / $2,390.19
| Professional | | $1,209.77 | $1,558.09 | $2,390.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.30 / $1,300.40 / $1,300.40
| Professional | | $922.30 | $1,300.40 | $1,300.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.89 / $1,443.59 / $2,205.83
| Professional | | $1,043.89 | $1,443.59 | $2,205.83 |