- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,479.11 / $2,630.27
| Professional | | $794.33 | $1,479.11 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $2,570.40
| Professional | | $1,071.52 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $2,570.40
| Professional | | $1,348.96 | $1,621.81 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,238.72
| Professional | | $1,445.44 | $1,698.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $3,388.44
| Professional | | $1,258.93 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,238.72
| Professional | | $1,202.26 | $1,698.24 | $2,238.72 |