- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.15 / $1,460.51 / $1,460.51
| Professional | | $902.15 | $1,460.51 | $1,460.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,384.69 / $1,601.45 / $2,313.25
| Professional | | $1,384.69 | $1,601.45 | $2,313.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.45 / $1,718.25 / $2,648.39
| Professional | | $1,050.45 | $1,718.25 | $2,648.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.85 / $1,739.79 / $2,668.93
| Professional | | $1,350.85 | $1,739.79 | $2,668.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.15 / $1,460.51 / $1,460.51
| Professional | | $902.15 | $1,460.51 | $1,460.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,261.51 / $1,698.18 / $2,433.96
| Professional | | $1,261.51 | $1,698.18 | $2,433.96 |