- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.85 / $1,545.77 / $2,846.21
| Professional | | $743.85 | $1,545.77 | $2,846.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $767.63 / $1,601.34 / $2,211.07
| Professional | | $767.63 | $1,601.34 | $2,211.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,167.65 / $1,932.64 / $3,921.37
| Professional | | $1,167.65 | $1,932.64 | $3,921.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,389.65 / $2,030.94 / $3,218.75
| Professional | | $1,389.65 | $2,030.94 | $3,218.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.25 / $2,985.54 / $4,871.34
| Professional | | $1,441.25 | $2,985.54 | $4,871.34 |