- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $884.51 / $901.20 / $901.20
| Professional | | $884.51 | $901.20 | $901.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.33 / $1,459.73 / $2,681.40
| Professional | | $1,238.33 | $1,459.73 | $2,681.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.43 / $1,283.67 / $1,673.25
| Professional | | $820.43 | $1,283.67 | $1,673.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $775.37 / $1,110.89 / $1,673.25
| Professional | | $775.37 | $1,110.89 | $1,673.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.85 / $1,050.94 / $1,782.29
| Professional | | $861.85 | $1,050.94 | $1,782.29 |