- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,548.82 / $3,981.07
| Professional | | $707.95 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $812.83 / $1,023.29
| Professional | | $724.44 | $812.83 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,548.82 / $3,162.28
| Professional | | $758.58 | $1,548.82 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,995.26 / $3,162.28
| Professional | | $1,659.59 | $1,995.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,412.54 / $2,951.21
| Professional | | $691.83 | $1,412.54 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,089.30 / $2,691.53
| Professional | | $776.25 | $2,089.30 | $2,691.53 |