- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $717.92 / $883.24 / $1,889.98
| Professional | | $717.92 | $883.24 | $1,889.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.11 / $1,276.21 / $3,910.77
| Professional | | $1,051.11 | $1,276.21 | $3,910.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.39 / $1,090.24 / $2,490.46
| Professional | | $766.39 | $1,090.24 | $2,490.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.84 / $1,267.70 / $2,490.46
| Professional | | $917.84 | $1,267.70 | $2,490.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.84 / $1,169.18 / $3,557.62
| Professional | | $917.84 | $1,169.18 | $3,557.62 |