- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $740.95 / $1,382.26 / $2,615.46
| Professional | | $740.95 | $1,382.26 | $2,615.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $943.36 / $1,109.83 / $2,439.71
| Professional | | $943.36 | $1,109.83 | $2,439.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.92 / $1,779.90 / $3,221.26
| Professional | | $871.92 | $1,779.90 | $3,221.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.32 / $2,215.10 / $12,126.80
| Professional | | $1,629.32 | $2,215.10 | $12,126.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,629.32 / $1,993.59 / $2,833.62
| Professional | | $1,629.32 | $1,993.59 | $2,833.62 |