- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,258.93 / $2,511.89
| Professional | | $794.33 | $1,258.93 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $1,548.82
| Professional | | $1,258.93 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $1,548.82
| Professional | | $741.31 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $1,905.46
| Professional | | $1,348.96 | $1,659.59 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,318.26 / $1,995.26
| Professional | | $79.43 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $1,862.09
| Professional | | $1,122.02 | $1,513.56 | $1,862.09 |