- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.62 / $1,020.70 / $1,265.47
| Professional | | $874.62 | $1,020.70 | $1,265.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.46 / $1,349.46 / $3,942.29
| Professional | | $1,111.46 | $1,349.46 | $3,942.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.10 / $1,307.09 / $2,869.52
| Professional | | $917.10 | $1,307.09 | $2,869.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.91 / $1,463.51 / $2,869.52
| Professional | | $1,064.91 | $1,463.51 | $2,869.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.91 / $1,329.12 / $4,127.68
| Professional | | $1,064.91 | $1,329.12 | $4,127.68 |