- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $933.25 / $2,290.87
| Professional | | $758.58 | $933.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $1,778.28
| Professional | | $758.58 | $1,202.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,202.26 / $1,862.09
| Professional | | $933.25 | $1,202.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,122.02 / $2,137.96
| Professional | | $933.25 | $1,122.02 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,148.15 / $2,290.87
| Professional | | $794.33 | $1,148.15 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,659.59
| Professional | | $707.95 | $1,047.13 | $1,659.59 |