- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,548.82 / $2,818.38
| Professional | | $707.95 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $1,778.28
| Professional | | $676.08 | $1,096.48 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,778.28 / $3,467.37
| Professional | | $933.25 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $2,041.74 / $3,311.31
| Professional | | $831.76 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,862.09 / $5,011.87
| Professional | | $831.76 | $1,862.09 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,513.56 / $3,235.94
| Professional | | $794.33 | $1,513.56 | $3,235.94 |