- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,548.82 / $2,630.27
| Professional | | $776.25 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,412.54 / $1,995.26
| Professional | | $676.08 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,137.96 / $4,897.79
| Professional | | $977.24 | $2,137.96 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,862.09 / $3,801.89
| Professional | | $831.76 | $1,862.09 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $3,890.45
| Professional | | $870.96 | $1,819.70 | $3,890.45 |