- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.41 / $998.41 / $1,055.40
| Professional | | $998.41 | $998.41 | $1,055.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.09 / $1,643.31 / $3,199.34
| Professional | | $1,394.09 | $1,643.31 | $3,199.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.00 / $1,431.48 / $1,914.52
| Professional | | $956.00 | $1,431.48 | $1,914.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.39 / $1,267.47 / $1,914.52
| Professional | | $880.39 | $1,267.47 | $1,914.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.49 / $1,202.49 / $3,495.72
| Professional | | $1,045.49 | $1,202.49 | $3,495.72 |