- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,230.27 / $3,235.94
| Professional | | $831.76 | $1,230.27 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,778.28
| Professional | | $1,513.56 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,380.38 / $2,187.76
| Professional | | $758.58 | $1,380.38 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,318.26 / $1,698.24
| Professional | | $1,023.29 | $1,318.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $4,073.80
| Professional | | $1,174.90 | $1,380.38 | $4,073.80 |