- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,096.48 / $2,884.03
| Professional | | $707.95 | $1,096.48 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $3,630.78
| Professional | | $1,202.26 | $1,412.54 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $1,698.24
| Professional | | $891.25 | $1,318.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $3,630.78
| Professional | | $1,659.59 | $1,659.59 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,258.93 / $3,801.89
| Professional | | $954.99 | $1,258.93 | $3,801.89 |