- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $1,096.48 / $1,949.84
| Professional | | $588.84 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,258.93 / $1,905.46
| Professional | | $776.25 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,202.26 / $1,905.46
| Professional | | $1,047.13 | $1,202.26 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $1,698.24
| Professional | | $1,071.52 | $1,288.25 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,318.26 / $2,691.53
| Professional | | $1,000.00 | $1,318.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,258.93 / $1,698.24
| Professional | | $912.01 | $1,258.93 | $1,698.24 |