- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $977.24 / $1,318.26
| Professional | | $812.83 | $977.24 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $2,041.74
| Professional | | $977.24 | $1,479.11 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,513.56 / $2,511.89
| Professional | | $977.24 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,778.28 / $2,691.53
| Professional | | $1,148.15 | $1,778.28 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $3,311.31
| Professional | | $1,071.52 | $1,621.81 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |