- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.99 / $994.13 / $2,538.23
| Professional | | $802.99 | $994.13 | $2,538.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.15 / $1,015.47 / $1,462.37
| Professional | | $863.15 | $1,015.47 | $1,462.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $996.12 / $1,816.72 / $3,627.55
| Professional | | $996.12 | $1,816.72 | $3,627.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.07 / $2,159.52 / $3,466.89
| Professional | | $955.07 | $2,159.52 | $3,466.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.63 / $994.13 / $2,538.23
| Professional | | $818.63 | $994.13 | $2,538.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.59 / $2,841.85 / $3,825.57
| Professional | | $1,695.59 | $2,841.85 | $3,825.57 |