- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,174.90 / $2,041.74
| Professional | | $741.31 | $1,174.90 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,348.96 / $2,041.74
| Professional | | $831.76 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,318.26 / $2,041.74
| Professional | | $1,174.90 | $1,318.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,318.26 / $1,698.24
| Professional | | $1,096.48 | $1,318.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $3,019.95
| Professional | | $1,071.52 | $1,445.44 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $1,905.46
| Professional | | $1,096.48 | $1,479.11 | $1,905.46 |