- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.68 / $881.09 / $881.09
| Professional | | $872.68 | $881.09 | $881.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.85 / $1,258.78 / $2,645.36
| Professional | | $1,067.85 | $1,258.78 | $2,645.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $809.71 / $1,266.33 / $1,650.83
| Professional | | $809.71 | $1,266.33 | $1,650.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.05 / $1,095.89 / $1,650.83
| Professional | | $765.05 | $1,095.89 | $1,650.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.43 / $1,019.97 / $3,014.21
| Professional | | $888.43 | $1,019.97 | $3,014.21 |