- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,548.82 / $3,548.13
| Professional | | $707.95 | $1,548.82 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,862.09 / $4,466.84
| Professional | | $776.25 | $1,862.09 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,041.74 / $2,818.38
| Professional | | $1,513.56 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.96 / $1,737.80 / $4,897.79
| Professional | | $630.96 | $1,737.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,412.54 / $3,467.37
| Professional | | $645.65 | $1,412.54 | $3,467.37 |