- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $853.20 / $855.71 / $855.71
| Professional | | $853.20 | $855.71 | $855.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.67 / $1,179.56 / $2,600.38
| Professional | | $1,000.67 | $1,179.56 | $2,600.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.02 / $1,213.33 / $1,611.80
| Professional | | $788.02 | $1,213.33 | $1,611.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.57 / $1,068.91 / $1,611.80
| Professional | | $744.57 | $1,068.91 | $1,611.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $862.72 / $939.15 / $2,942.99
| Professional | | $862.72 | $939.15 | $2,942.99 |