- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.68 / $1,240.66 / $1,240.66
| Professional | | $866.68 | $1,240.66 | $1,240.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.44 / $1,044.95 / $1,579.83
| Professional | | $858.44 | $1,044.95 | $1,579.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.70 / $1,305.20 / $2,886.05
| Professional | | $1,021.70 | $1,305.20 | $2,886.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.13 / $997.52 / $1,552.14
| Professional | | $896.13 | $997.52 | $1,552.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.68 / $1,240.66 / $1,240.66
| Professional | | $866.68 | $1,240.66 | $1,240.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.58 / $1,218.44 / $1,523.04
| Professional | | $1,096.58 | $1,218.44 | $1,523.04 |