- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.14 / $811.14 / $811.14
| Professional | | $811.14 | $811.14 | $811.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,014.06 / $1,280.64 / $2,030.92
| Professional | | $1,014.06 | $1,280.64 | $2,030.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.28 / $1,393.13 / $2,286.83
| Professional | | $822.28 | $1,393.13 | $2,286.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.35 / $1,592.69 / $2,359.46
| Professional | | $1,329.35 | $1,592.69 | $2,359.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $811.14 / $811.14 / $811.14
| Professional | | $811.14 | $811.14 | $811.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $983.46 / $1,412.01 / $2,238.09
| Professional | | $983.46 | $1,412.01 | $2,238.09 |