- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,122.02 / $1,659.59
| Professional | | $630.96 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,089.30
| Professional | | $851.14 | $1,348.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,318.26 / $2,041.74
| Professional | | $1,202.26 | $1,318.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,318.26 / $1,737.80
| Professional | | $1,096.48 | $1,318.26 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,318.26 / $1,659.59
| Professional | | $1,071.52 | $1,318.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $1,778.28
| Professional | | $1,096.48 | $1,380.38 | $1,778.28 |