- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,698.24 / $2,951.21
| Professional | | $831.76 | $1,698.24 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $2,951.21
| Professional | | $1,202.26 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,819.70 / $2,951.21
| Professional | | $1,513.56 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $2,511.89
| Professional | | $1,621.81 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $3,890.45
| Professional | | $1,513.56 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $2,511.89
| Professional | | $1,258.93 | $1,819.70 | $2,511.89 |