- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,318.26 / $2,290.87
| Professional | | $691.83 | $1,318.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,513.56 / $2,290.87
| Professional | | $933.25 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,412.54 / $2,290.87
| Professional | | $1,230.27 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $1,949.84
| Professional | | $1,258.93 | $1,513.56 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $3,090.30
| Professional | | $1,122.02 | $1,584.89 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $1,949.84
| Professional | | $1,047.13 | $1,479.11 | $1,949.84 |