- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $467.74 / $812.83
| Professional | | $346.74 | $467.74 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,778.28
| Professional | | $691.83 | $1,047.13 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,479.11 / $2,344.23
| Professional | | $891.25 | $1,479.11 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,348.96 / $2,187.76
| Professional | | $851.14 | $1,348.96 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $1,023.29 / $5,011.87
| Professional | | $575.44 | $1,023.29 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $870.96 / $1,659.59
| Professional | | $537.03 | $870.96 | $1,659.59 |