- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,454.71
| Professional | | $933.25 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,659.59 / $2,137.96
| Professional | | $1,071.52 | $1,659.59 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $2,454.71
| Professional | | $1,202.26 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $2,344.23
| Professional | | $1,380.38 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $3,162.28
| Professional | | $933.25 | $1,380.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,454.71
| Professional | | $1,096.48 | $1,584.89 | $2,454.71 |