- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.78 / $2,817.63 / $2,817.63
| Professional | | $983.78 | $2,817.63 | $2,817.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,266.26 / $2,463.33 / $2,468.63
| Professional | | $2,266.26 | $2,463.33 | $2,468.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,141.04 / $2,817.63 / $4,032.52
| Professional | | $2,141.04 | $2,817.63 | $4,032.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.90 / $2,563.46 / $3,988.76
| Professional | | $2,302.90 | $2,563.46 | $3,988.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.78 / $2,817.63 / $2,817.63
| Professional | | $983.78 | $2,817.63 | $2,817.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.00 / $4,232.06 / $5,107.66
| Professional | | $2,512.00 | $4,232.06 | $5,107.66 |