- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.27 / $735.27 / $1,484.92
| Professional | | $735.27 | $735.27 | $1,484.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $911.52 / $1,148.09 / $1,763.22
| Professional | | $911.52 | $1,148.09 | $1,763.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $709.80 / $1,255.31 / $1,974.00
| Professional | | $709.80 | $1,255.31 | $1,974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,161.58 / $1,391.69 / $2,061.69
| Professional | | $1,161.58 | $1,391.69 | $2,061.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $735.27 / $966.86 / $1,484.92
| Professional | | $735.27 | $966.86 | $1,484.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $894.30 / $1,277.19 / $2,061.69
| Professional | | $894.30 | $1,277.19 | $2,061.69 |