- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $2,041.74
| Professional | | $954.99 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,862.09 / $2,630.27
| Professional | | $870.96 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,778.28 / $3,235.94
| Professional | | $1,174.90 | $1,778.28 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $2,290.87
| Professional | | $1,023.29 | $1,584.89 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $2,951.21
| Professional | | $1,047.13 | $1,584.89 | $2,951.21 |