- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $3,019.95
| Professional | | $954.99 | $1,258.93 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,548.82 / $2,238.72
| Professional | | $954.99 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $2,454.71
| Professional | | $1,148.15 | $1,513.56 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $2,137.96
| Professional | | $1,202.26 | $1,412.54 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $3,801.89
| Professional | | $1,096.48 | $1,479.11 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $2,137.96
| Professional | | $1,122.02 | $1,479.11 | $2,137.96 |