- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $925.13 / $933.69 / $933.69
| Professional | | $925.13 | $933.69 | $933.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.45 / $1,254.74 / $2,774.20
| Professional | | $1,064.45 | $1,254.74 | $2,774.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $847.89 / $1,331.06 / $1,752.94
| Professional | | $847.89 | $1,331.06 | $1,752.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.16 / $1,162.54 / $1,752.94
| Professional | | $812.16 | $1,162.54 | $1,752.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $899.89 / $1,101.00 / $1,870.33
| Professional | | $899.89 | $1,101.00 | $1,870.33 |