- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $828.20 / $1,011.40 / $2,191.29
| Professional | | $828.20 | $1,011.40 | $2,191.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,247.75 / $1,514.94 / $4,642.35
| Professional | | $1,247.75 | $1,514.94 | $4,642.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.81 / $1,265.60 / $2,857.37
| Professional | | $884.81 | $1,265.60 | $2,857.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.29 / $1,458.80 / $2,857.37
| Professional | | $1,059.29 | $1,458.80 | $2,857.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.29 / $1,380.62 / $4,105.92
| Professional | | $1,059.29 | $1,380.62 | $4,105.92 |