- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,630.27
| Professional | | $891.25 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,445.44 / $2,344.23
| Professional | | $870.96 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,187.76
| Professional | | $1,096.48 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $2,454.71
| Professional | | $1,071.52 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $3,162.28
| Professional | | $1,023.29 | $1,479.11 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,454.71
| Professional | | $977.24 | $1,479.11 | $2,454.71 |