- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.11 / $1,389.62 / $1,389.62
| Professional | | $977.11 | $1,389.62 | $1,389.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.64 / $1,191.33 / $1,754.42
| Professional | | $963.64 | $1,191.33 | $1,754.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,176.95 / $1,389.62 / $1,952.42
| Professional | | $1,176.95 | $1,389.62 | $1,952.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.66 / $1,137.26 / $1,769.58
| Professional | | $1,021.66 | $1,137.26 | $1,769.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.11 / $1,389.62 / $1,389.62
| Professional | | $977.11 | $1,389.62 | $1,389.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,033.84 / $1,312.76 / $1,584.36
| Professional | | $1,033.84 | $1,312.76 | $1,584.36 |