- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,096.48 / $2,754.23
| Professional | | $676.08 | $1,096.48 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,258.93
| Professional | | $1,071.52 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,047.13 / $1,737.80
| Professional | | $676.08 | $1,047.13 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,071.52 / $1,258.93
| Professional | | $794.33 | $1,071.52 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,071.52 / $3,162.28
| Professional | | $891.25 | $1,071.52 | $3,162.28 |