- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,202.26 / $2,137.96
| Professional | | $691.83 | $1,202.26 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,380.38 / $2,137.96
| Professional | | $870.96 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,318.26 / $2,089.30
| Professional | | $1,148.15 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $1,819.70
| Professional | | $1,148.15 | $1,380.38 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $2,818.38
| Professional | | $1,071.52 | $1,479.11 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,819.70
| Professional | | $1,023.29 | $1,380.38 | $1,819.70 |