- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $771.57 / $938.95 / $2,047.65
| Professional | | $771.57 | $938.95 | $2,047.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,154.58 / $1,401.82 / $4,295.68
| Professional | | $1,154.58 | $1,401.82 | $4,295.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.98 / $1,182.59 / $2,649.33
| Professional | | $824.98 | $1,182.59 | $2,649.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.28 / $1,351.37 / $2,649.33
| Professional | | $984.28 | $1,351.37 | $2,649.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $984.28 / $1,277.11 / $3,815.16
| Professional | | $984.28 | $1,277.11 | $3,815.16 |