- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,584.89 / $2,754.23
| Professional | | $831.76 | $1,584.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $2,754.23
| Professional | | $1,122.02 | $1,819.70 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,698.24 / $2,754.23
| Professional | | $1,479.11 | $1,698.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,344.23
| Professional | | $1,513.56 | $1,778.28 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $3,801.89
| Professional | | $1,348.96 | $1,905.46 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $2,454.71
| Professional | | $1,348.96 | $1,862.09 | $2,454.71 |