- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.96 / $908.32 / $908.32
| Professional | | $903.96 | $908.32 | $908.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.08 / $1,329.76 / $2,746.22
| Professional | | $1,128.08 | $1,329.76 | $2,746.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.85 / $1,304.32 / $1,703.92
| Professional | | $836.85 | $1,304.32 | $1,703.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.48 / $1,130.52 / $1,703.92
| Professional | | $788.48 | $1,130.52 | $1,703.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.28 / $1,070.20 / $3,111.15
| Professional | | $933.28 | $1,070.20 | $3,111.15 |