- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.74 / $1,109.61 / $2,315.76
| Professional | | $881.74 | $1,109.61 | $2,315.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.28 / $1,339.88 / $3,978.40
| Professional | | $1,086.28 | $1,339.88 | $3,978.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.01 / $1,335.06 / $3,109.99
| Professional | | $930.01 | $1,335.06 | $3,109.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.91 / $1,571.67 / $3,109.99
| Professional | | $1,144.91 | $1,571.67 | $3,109.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.91 / $1,526.55 / $4,437.78
| Professional | | $1,144.91 | $1,526.55 | $4,437.78 |