- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $688.12 / $959.35 / $965.83
| Professional | | $688.12 | $959.35 | $965.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,109.22 / $1,307.54 / $2,944.57
| Professional | | $1,109.22 | $1,307.54 | $2,944.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.91 / $1,353.38 / $1,819.48
| Professional | | $891.91 | $1,353.38 | $1,819.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.12 / $1,206.06 / $1,819.48
| Professional | | $840.12 | $1,206.06 | $1,819.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.37 / $1,142.79 / $3,322.18
| Professional | | $969.37 | $1,142.79 | $3,322.18 |