- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,202.26 / $2,187.76
| Professional | | $691.83 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $2,187.76
| Professional | | $891.25 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $2,187.76
| Professional | | $1,202.26 | $1,348.96 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $1,862.09
| Professional | | $1,202.26 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,513.56 / $3,019.95
| Professional | | $691.83 | $1,513.56 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $1,949.84
| Professional | | $1,096.48 | $1,479.11 | $1,949.84 |