- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.31 / $855.31 / $865.76
| Professional | | $855.31 | $855.31 | $865.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,039.90 / $1,225.82 / $2,630.55
| Professional | | $1,039.90 | $1,225.82 | $2,630.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $802.69 / $1,239.22 / $1,636.46
| Professional | | $802.69 | $1,239.22 | $1,636.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $757.47 / $1,085.99 / $1,636.46
| Professional | | $757.47 | $1,085.99 | $1,636.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.51 / $1,027.83 / $2,988.00
| Professional | | $865.51 | $1,027.83 | $2,988.00 |