- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.76 / $2,575.57 / $2,575.57
| Professional | | $974.76 | $2,575.57 | $2,575.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,790.96 / $2,069.55 / $2,086.73
| Professional | | $1,790.96 | $2,069.55 | $2,086.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,062.33 / $2,575.57 / $3,786.62
| Professional | | $2,062.33 | $2,575.57 | $3,786.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,184.77 / $2,431.98 / $3,784.16
| Professional | | $2,184.77 | $2,431.98 | $3,784.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $974.76 / $2,575.57 / $2,575.57
| Professional | | $974.76 | $2,575.57 | $2,575.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.73 / $3,709.36 / $4,476.82
| Professional | | $2,201.73 | $3,709.36 | $4,476.82 |