- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,230.27 / $2,511.89
| Professional | | $891.25 | $1,230.27 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $3,548.13
| Professional | | $1,905.46 | $1,905.46 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $2,238.72
| Professional | | $954.99 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,621.81
| Professional | | $1,023.29 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $4,073.80
| Professional | | $1,148.15 | $1,445.44 | $4,073.80 |