- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.75 / $974.76 / $2,252.48
| Professional | | $974.75 | $974.76 | $2,252.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,510.45 / $1,670.87 / $1,693.65
| Professional | | $1,510.45 | $1,670.87 | $1,693.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,745.95 / $2,252.48 / $3,293.81
| Professional | | $1,745.95 | $2,252.48 | $3,293.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,681.16 / $1,871.39 / $2,911.88
| Professional | | $1,681.16 | $1,871.39 | $2,911.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.75 / $974.76 / $2,252.48
| Professional | | $974.75 | $974.76 | $2,252.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.27 / $2,093.12 / $2,911.88
| Professional | | $1,659.27 | $2,093.12 | $2,911.88 |