- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,318.26 / $2,290.87
| Professional | | $707.95 | $1,318.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,479.11 / $2,290.87
| Professional | | $912.01 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,412.54 / $2,290.87
| Professional | | $776.25 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $1,905.46
| Professional | | $1,230.27 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $3,090.30
| Professional | | $1,202.26 | $1,584.89 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,548.82 / $2,041.74
| Professional | | $891.25 | $1,548.82 | $2,041.74 |