- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.83 / $938.15 / $938.15
| Professional | | $888.83 | $938.15 | $938.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.07 / $1,328.56 / $2,702.67
| Professional | | $1,127.07 | $1,328.56 | $2,702.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.49 / $1,300.15 / $1,682.15
| Professional | | $818.49 | $1,300.15 | $1,682.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.10 / $1,168.07 / $1,682.15
| Professional | | $778.10 | $1,168.07 | $1,682.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.19 / $1,111.59 / $3,071.39
| Professional | | $1,023.19 | $1,111.59 | $3,071.39 |