- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $3,890.45
| Professional | | $933.25 | $1,148.15 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,513.56 / $3,235.94
| Professional | | $933.25 | $1,513.56 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,122.02 / $1,548.82
| Professional | | $912.01 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,380.38 / $4,265.80
| Professional | | $891.25 | $1,380.38 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,096.48 / $2,754.23
| Professional | | $776.25 | $1,096.48 | $2,754.23 |