- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $805.56 / $942.01 / $2,115.07
| Professional | | $805.56 | $942.01 | $2,115.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,053.24 / $1,278.78 / $3,767.95
| Professional | | $1,053.24 | $1,278.78 | $3,767.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.60 / $1,216.88 / $2,669.98
| Professional | | $861.60 | $1,216.88 | $2,669.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.59 / $1,358.27 / $2,669.98
| Professional | | $988.59 | $1,358.27 | $2,669.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $988.59 / $1,222.93 / $3,831.85
| Professional | | $988.59 | $1,222.93 | $3,831.85 |