- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $2,089.30
| Professional | | $933.25 | $1,148.15 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $1,949.84
| Professional | | $831.76 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,041.74
| Professional | | $1,122.02 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $1,862.09
| Professional | | $1,047.13 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $3,090.30
| Professional | | $933.25 | $1,318.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,380.38 / $2,041.74
| Professional | | $977.24 | $1,380.38 | $2,041.74 |