- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $2,691.53
| Professional | | $891.25 | $1,096.48 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $2,089.30
| Professional | | $891.25 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $2,187.76
| Professional | | $1,096.48 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $2,511.89
| Professional | | $1,122.02 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,691.53
| Professional | | $933.25 | $1,348.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,230.27 / $2,089.30
| Professional | | $831.76 | $1,230.27 | $2,089.30 |